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Suárez Ferrer C, Mesonero Gismero F, Caballol B, Ballester MP, Bastón Rey I, Castaño García A, Miranda Bautista J, Saiz Chumillas R, Benitez JM, Sanchez-Delgado L, López-García A, Rubin de Celix C, Alonso Abreu I, Melcarne L, Plaza Santos R, Marques-Camí M, Caballero Mateos A, Gómez Díez C, Calafat M, Galan HA, Vega Vilaamil P, Castro Senosiain B, Guerro Moya A, Rodriguez Diaz CY, Spicakova K, Manceñido Marcos N, Molina G, de Castro Parga L, Rodriguez Angulo A, Cuevas Del Campo L, Rodriguez Grau MDC, Ramirez F, Gomez Pastrana B, Gonzalez Partida I, Botella Mateu B, Peña Gonzalez E, Iyo E, Elosua Gonzalez A, Sainz Arnau E, Hernandez Villalba L, Perez Galindo P, Torrealba Medina L, Monsalve Alonso S, Olmos Perez JA, Dueñas Sadornil C, Garcia Ramirez L, Martín-Arranz MD, López Sanroman A, Fernández A, Merino Murgui V, Calviño Suárez C, Flórez-Diez P, Lobato Matilla ME, Sicilia B, Soto Escribano P, Maroto Martin C, Mañosa M, Barreiro-De Acosta M. Efficacy and safety of biological treatment for inflammatory bowel disease in elderly patients: Results from a GETECCU cohort. GASTROENTEROLOGIA Y HEPATOLOGIA 2024:S0210-5705(24)00155-9. [PMID: 38710465 DOI: 10.1016/j.gastrohep.2024.502197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/07/2024] [Accepted: 02/27/2024] [Indexed: 05/08/2024]
Abstract
INTRODUCTION Biological therapies used for the treatment of inflammatory bowel disease (IBD) have shown to be effective and safe, although these results were obtained from studies involving mostly a young population, who are generally included in clinical trials. The aim of our study was to determine the efficacy and safety of the different biological treatments in the elderly population. METHODS Multicenter study was carried out in the GETECCU group. Patients diagnosed with IBD and aged over 65 years at the time of initiating biological therapy (infliximab, adalimumab, golimumab, ustekinumab or vedolizumab) were retrospectively included. Among the patients included, clinical response was assessed after drug induction (12 weeks of treatment) and at 52 weeks. Patients' colonoscopy data in week 52 were assessment, where available. Regarding complications, development of oncological events during follow-up and infectious processes occurring during biological treatment were collected (excluding bowel infection by cytomegalovirus). RESULTS A total of 1090 patients were included. After induction, at approximately 12-14 weeks of treatment, 419 patients (39.6%) were in clinical remission, 502 patients (47.4%) had responded without remission and 137 patients (12.9%) had no response. At 52 weeks of treatment 442 patients (57.1%) had achieved clinical remission, 249 patients had responded without remission (32.2%) and 53 patients had no response to the treatment (6.8%). Before 52 weeks, 129 patients (14.8%) had discontinued treatment due to inefficacy, this being significantly higher (p<0.0001) for Golimumab - 9 patients (37.5%) - compared to the other biological treatments analyzed. With respect to tumor development, an oncological event was observed in 74 patients (6.9%): 30 patients (8%) on infliximab, 23 (7.14%) on adalimumab, 3 (11.1%) on golimumab, 10 (6.4%) on ustekinumab, and 8 (3.8%) on vedolizumab. The incidence was significantly lower (p=0.04) for the vedolizumab group compared to other treatments. As regards infections, these occurred in 160 patients during treatment (14.9%), with no differences between the different biologicals used (p=0.61): 61 patients (19.4%) on infliximab, 39 (12.5%) on adalimumab, 5 (17.8%) on golimumab, 22 (14.1%) on ustekinumab, and 34 (16.5%) on vedolizumab. CONCLUSIONS Biological drug therapies have response rates in elderly patients similar to those described in the general population, Golimumab was the drug that was discontinued most frequently due to inefficacy. In our experience, tumor development was more frequent in patients who used anti-TNF therapies compared to other targets, although its incidence was generally low and that this is in line with younger patients based on previous literature.
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Affiliation(s)
- Cristina Suárez Ferrer
- Gastroenterology Department, School of Medicine, Universidad Autónoma de Madrid, Hospital La Paz Institute for Health Research, La Paz Hospital, Madrid, Spain.
| | | | - Berta Caballol
- Gastroenterology Department, Hospital Clinic of Barcelona, Barcelona, Spain
| | | | - Iria Bastón Rey
- Gastroenterology Department, Hospital Universitario Clínico de Santiago, Santiago de Compostela, Spain
| | - Andrés Castaño García
- Gastroenterology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | - Rosa Saiz Chumillas
- Gastroenterology Department, Hospital Universitario de Burgos, Burgos, Spain
| | - Jose Manuel Benitez
- Gastroenterology Department, Hospital Universitario Reina Sofia, Cordoba, Spain
| | | | - Alicia López-García
- Gastroneterology Department, Hospital del Mar, IMIM (Institut de Recerca Hospital del Mar ó Research Institute Hospital del Mar), Barcelona, Spain
| | - Cristina Rubin de Celix
- Gastroenterology Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IISIP), Madrid, Spain
| | - Inmaculada Alonso Abreu
- Gastroenterology Department, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
| | - Luigi Melcarne
- Gastroenterology Department, Hospital Universitari Parc Taulli, Sabadel, Barcelona, Spain
| | - Rocío Plaza Santos
- Gastroenterology Department, Infanta Leonor University Hospital, Madrid, Spain
| | | | | | - César Gómez Díez
- Gastroenterology Department, Hospital Universitario Cabueñes, Gijón, Spain
| | - Margalida Calafat
- Gastroenterology Department, Hospital Germans Trias i Pujol, Badalona, Ciberehd, Spain
| | | | - Pablo Vega Vilaamil
- Gastroenterology Department, Complexo Hospitalario Universitario de Ourense, Spain
| | - Beatriz Castro Senosiain
- Gastroenterology Department, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Andrea Guerro Moya
- Gastroenterology Department, Complexo Hospitalario Universitario A Coruña, Spain
| | | | - Katerina Spicakova
- Gastroenterology Department, Hospital Universitario de Alava, Vitoria, Spain
| | | | - Gema Molina
- Gastroenterology Department, Hospital Universitario de Ferrol, A Coruña, Spain
| | | | | | | | | | - Fernando Ramirez
- Gastroneterology Department, Ciudad Real University Hospital, Ciudad Real, Spain
| | | | - Irene Gonzalez Partida
- Gastroenterology Department, Puerta de Hierro University Hospital, Majadahonda, Madrid, Spain
| | - Belen Botella Mateu
- Gastroenterology Department, Hospital Univesitario Infanta Cristina, Parla, Madrid, Spain
| | | | - Eduardo Iyo
- Gastroenterology Department, Hospital Comarcal de Inca, Baleares, Spain
| | | | - Empar Sainz Arnau
- Gastroenterology Department, Hospital Xara Assistencial Althaia de Manressa, Spain
| | | | - Pablo Perez Galindo
- Gastroenterology Department, Pontevedra University Hospital Complex, Pontevedra, Spain
| | | | | | | | | | - Laura Garcia Ramirez
- Gastroenterology Department, School of Medicine, Universidad Autónoma de Madrid, Hospital La Paz Institute for Health Research, La Paz Hospital, Madrid, Spain
| | - María Dolores Martín-Arranz
- Gastroenterology Department, School of Medicine, Universidad Autónoma de Madrid, Hospital La Paz Institute for Health Research, La Paz Hospital, Madrid, Spain
| | | | - Agnès Fernández
- Gastroenterology Department, Hospital Clinic of Barcelona, Barcelona, Spain
| | | | - Cristina Calviño Suárez
- Gastroenterology Department, Hospital Universitario Clínico de Santiago, Santiago de Compostela, Spain
| | - Pablo Flórez-Diez
- Gastroenterology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | - Beatriz Sicilia
- Gastroenterology Department, Hospital Universitario de Burgos, Burgos, Spain
| | | | - Carlos Maroto Martin
- Gastroenterology Department, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Míriam Mañosa
- Gastroenterology Department, Hospital Germans Trias i Pujol, Badalona, Ciberehd, Spain
| | - Manuel Barreiro-De Acosta
- Gastroenterology Department, Hospital Universitario Clínico de Santiago, Santiago de Compostela, Spain
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Triantafillidis JK, Zografos CG, Konstadoulakis MM, Papalois AE. Combination treatment of inflammatory bowel disease: Present status and future perspectives. World J Gastroenterol 2024; 30:2068-2080. [PMID: 38681984 PMCID: PMC11045479 DOI: 10.3748/wjg.v30.i15.2068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 02/20/2024] [Accepted: 03/28/2024] [Indexed: 04/19/2024] Open
Abstract
The treatment of patients with inflammatory bowel disease (IBD), especially those with severe or refractory disease, represents an important challenge for the clinical gastroenterologist. It seems to be no exaggeration to say that in these patients, not only the scientific background of the gastroenterologist is tested, but also the abundance of "gifts" that he should possess (insight, intuition, determination, ability to take initiative, etc.) for the successful outcome of the treatment. In daily clinical practice, depending on the severity of the attack, IBD is treated with one or a combination of two or more pharmaceutical agents. These combinations include not only the first-line drugs (e.g., mesalazine, corticosteroids, antibiotics, etc) but also second- and third-line drugs (immunosuppressants and biologic agents). It is a fact that despite the significant therapeutic advances there is still a significant percentage of patients who do not satisfactorily respond to the treatment applied. Therefore, a part of these patients are going to surgery. In recent years, several small-size clinical studies, reviews, and case reports have been published combining not only biological agents with other drugs (e.g., immunosuppressants or corticosteroids) but also the combination of two biological agents simultaneously, especially in severe cases. In our opinion, it is at least a strange (and largely unexplained) fact that we often use combinations of drugs in a given patient although studies comparing the simultaneous administration of two or more drugs with monotherapy are very few. As mentioned above, there is a timid tendency in the literature to combine two biological agents in severe cases unresponsive to the applied treatment or patients with severe extraintestinal manifestations. The appropriate dosage, the duration of the administration, the suitable timing for checking the clinical and laboratory outcome, as well as the treatment side-effects, should be the subject of intense clinical research shortly. In this editorial, we attempt to summarize the existing data regarding the already applied combination therapies and to humbly formulate thoughts and suggestions for the future application of the combination treatment of biological agents in a well-defined category of patients. We suggest that the application of biomarkers and artificial intelligence could help in establishing new forms of treatment using the available modern drugs in patients with IBD resistant to treatment.
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Affiliation(s)
- John K Triantafillidis
- Inflammatory Bowel Disease Unit, "Metropolitan General" Hospital, Holargos 15562, Attica, Greece
- Hellenic Society for Gastrointestinal Oncology, 354 Iera Odos, Chaidari 12461, Attica, Greece
| | - Constantinos G Zografos
- The 2nd Department of Surgery, University of Athens, School of Medicine, Aretaieion Hospital, Athens 11528, Greece
| | - Manousos M Konstadoulakis
- The 2nd Department of Surgery, University of Athens, School of Medicine, Aretaieion Hospital, Athens 11528, Greece
| | - Apostolos E Papalois
- Unit of Surgical Research and Training, The 2nd Department of Surgery, University of Athens, School of Medicine, Aretaieion Hospital, Athens 11528, Greece
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Devi J, Ballard DH, Aswani-Omprakash T, Parian AM, Deepak P. Perianal fistulizing Crohn's disease: Current perspectives on diagnosis, monitoring and management with a focus on emerging therapies. Indian J Gastroenterol 2024; 43:48-63. [PMID: 38308773 DOI: 10.1007/s12664-024-01524-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/02/2024] [Indexed: 02/05/2024]
Abstract
Crohn's disease (CD), a chronic inflammatory bowel disorder, manifests in various phenotypes, with fistulizing perianal CD (CD-PAF) being one of its most severe phenotypes. Characterized by fistula formation and abscesses, CD-PAF impacts 17% to 34% of all CD cases and with a significantly deleterious impact on patient's quality of life, while increasing the risk for anorectal cancers. The pathogenesis involves a complex interplay of genetic, immunological and environmental factors, with cytokines such as tumor necrosis factor-alpha (TNF-α) and transforming growth factor-beta (TGF-β) playing pivotal roles. Diagnostic protocols require a multi-disciplinary approach including colonoscopy, examination under anesthesia and magnetic resonance imaging. In terms of treatment, biologics alone often prove inadequate, making surgical interventions such as setons and fistula surgeries essential. Emerging therapies such as mesenchymal stem cells are under study. The South Asian context adds layers of complexity, including diagnostic ambiguities related to high tuberculosis prevalence, healthcare access limitations and cultural stigma toward perianal Crohn's disease and ostomy surgery. Effective management necessitates an integrated, multi-disciplinary approach, especially in resource-constrained settings. Despite advances, there remain significant gaps in understanding the disease's pathophysiology and a dearth of standardized outcome measures, underscoring the urgent need for comprehensive research.
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Affiliation(s)
- Jalpa Devi
- Division of Gastroenterology, John T. Milliken Department of Medicine, Washington University School of Medicine in Saint Louis, 660 S. Euclid Avenue, Campus Box 8124, Saint Louis, MO, 63110, USA
| | - David H Ballard
- Mallinckrodt Institute of Radiology, Washington University School of Medicine in Saint Louis, St. Louis, MO, USA
| | | | - Alyssa M Parian
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, MD, USA
| | - Parakkal Deepak
- Division of Gastroenterology, John T. Milliken Department of Medicine, Washington University School of Medicine in Saint Louis, 660 S. Euclid Avenue, Campus Box 8124, Saint Louis, MO, 63110, USA.
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Miyatani Y, Choi D, Choi NK, Rubin DT. Dual-Targeted Therapy with Upadacitinib and Ustekinumab in Medically Complex Crohn's Disease. Dig Dis Sci 2024; 69:355-359. [PMID: 38112840 DOI: 10.1007/s10620-023-08182-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/02/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND AND AIMS Ongoing efforts to break the therapeutic ceiling in inflammatory bowel disease include combination therapy approaches. Dual-targeted therapy (DTT) has been reported in case reports and small case series. This report describes our experience with ustekinumab (UST) and upadacitinib (UPA) as DTT in patients with Crohn's disease (CD). METHODS In this retrospective, observational study, we reviewed medical records of patients with CD treated with combined UST and UPA between April 2021 and July 2022. Clinical remission was defined as Harvey-Bradshaw Index (HBI) ≤ 4, and clinical response was defined as decrease in HBI ≥ 3 or physician's assessment of clinical response. RESULTS We identified 10 CD patients treated with UST/UPA, with median follow-up period of 10 months (interquartile range (IQR) 7.3-12). Median age was 35.5 years (IQR 28.3-43.8) and median number of prior biologic treatment exposures was 4 (IQR 4-5). Indications for UST/UPA were active CD (n = 6), extraintestinal manifestations (EIM) (n = 2), and both active CD and EIM (n = 2). Five of six patients with active CD achieved clinical remission with UST/UPA. Two patients with active EIM (joint pain) achieved resolution of their symptoms. One patient exhibited improvement in both conditions. Three patients developed mild respiratory symptoms and one experienced bowel obstruction. Two patients developed nausea resulting in de-escalation of treatment interval or discontinuation altogether. CONCLUSION Based on our case series, combination therapy with UST and UPA may be effective and appears safe in refractory Crohn's disease and for patients with co-existing extraintestinal manifestations.
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Affiliation(s)
- Yusuke Miyatani
- Department of Medicine, University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - David Choi
- Department of Medicine, University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Natalie K Choi
- Department of Medicine, University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - David T Rubin
- Department of Medicine, University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA.
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Valero-Martínez C, Urgelles JF, Sallés M, Joven-Ibáñez BE, de Juanes A, Ramírez J, Juanola X, Almodóvar R, Laiz A, Moreno M, Pujol M, Beltrán E, Pinto-Tasende JA, Crespí L, Sala-Icardo L, Castañeda S, García-Vicuña R. Dual targeted therapy in patients with psoriatic arthritis and spondyloarthritis: a real-world multicenter experience from Spain. Front Immunol 2023; 14:1283251. [PMID: 37936691 PMCID: PMC10627177 DOI: 10.3389/fimmu.2023.1283251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 10/10/2023] [Indexed: 11/09/2023] Open
Abstract
Dual targeted therapy (DTT) has emerged as a promising approach in patients with refractory spondyloarthritis (SpA) or psoriatic arthritis (PsA) and extra-musculoskeletal manifestations of both diseases, but its effectiveness/safety ratio still remains unclear. This is a retrospective, real-world multicenter study in refractory SpA and PsA patients with simultaneous use of two biological or synthetic targeted agents. Effectiveness was assessed using Ankylosing Spondylitis Disease Activity Score with C-reactive protein (ASDAS-CRP) and Disease Activity in Psoriatic Arthritis (DAPSA) Score. We identified 39 different DTT combinations in 36 patients (22 SpA; 14 PsA), 25 of them with concomitant inflammatory bowel disease. The most commonly used combinations were TNF inhibitor plus antagonist of the IL12/23 pathway, followed by TNF inhibitor plus IL-17 antagonist. During a median exposure of 14.86 months (IQR 8-20.2), DTT retention rate was 69.4% (n=25/36; 19 SpA, 6 PsA). Major clinical improvement (change in ASDAS-CRP > 2 or improvement > 85% in DAPSA) was achieved in 69.4% of patients (n=25/36 therapeutical combinations; 17/21 SpA, 8/15 PsA), with a 58.3% (n=21/36 combinations; 15/20 SpA, 6/13 PsA) low-activity/remission rate. Of the patients who were receiving glucocorticoids, 55% managed to withdraw them during follow-up. Interestingly, only four serious adverse events in three patients were observed, leading to DTT discontinuation.
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Affiliation(s)
| | | | - Meritxell Sallés
- Rheumatology Unit, Althaia Xarxa Assistencial Universitària, Manresa, Spain
| | | | | | - Julio Ramírez
- Rheumatology Unit, Hospital Clinic, Barcelona, Spain
| | - Xavier Juanola
- Rheumatology Unit, Hospital U. Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Raquel Almodóvar
- Rheumatology Unit, Hospital U. Fundación Alcorcón, Madrid, Spain
| | - Ana Laiz
- Rheumatology Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Mireia Moreno
- Rheumatology Unit, Hospital U. Parc Taulí, I3PT (UAB), Sabadell, Spain
| | - Manel Pujol
- Rheumatology Unit, Hospital U, Mútua Terrassa, Barcelona, Spain
| | - Emma Beltrán
- Rheumatology Unit, Hospital del Mar, Barcelona, Spain
| | | | - Laura Crespí
- Rheumatology Unit, Hospital de Manacor, Manacor, Spain
| | | | - Santos Castañeda
- Rheumatology Unit, Hospital U. de La Princesa, IIS-Princesa, Madrid, Spain
- Cátedra Universidad Autónoma de Madrid UAM-Roche, enfermedad pulmonar intersticial difusa (EPID)-Future, Department of Medicine, Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Rosario García-Vicuña
- Rheumatology Unit, Hospital U. de La Princesa, IIS-Princesa, Madrid, Spain
- Department of Medicine, Universidad Autónoma de Madrid (UAM), Madrid, Spain
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Hanzel J, Ma C, Jairath V. Mirikizumab for the treatment of moderate to severe ulcerative colitis. Immunotherapy 2023; 15:1199-1208. [PMID: 37465925 DOI: 10.2217/imt-2023-0012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
Despite a growing number of available therapeutic options for ulcerative colitis (UC), up to 50% of patients do not respond to initial treatment or lose response over time, highlighting the need for novel therapies. The IL-23 pathway has emerged as an important therapeutic target for UC. Mirikizumab is a humanized IgG4 monoclonal antibody against the p19 subunit of IL-23, dosed intravenously during induction and subcutaneously during maintenance. It is effective for the induction and maintenance of remission in moderately to severely active UC, including patients with prior failure of biological or tofacitinib therapy. Like other IL-23 antagonists, mirikizumab has a favorable safety profile. It is the first agent of its class to receive regulatory approval for moderately to severely active UC in Europe.
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Affiliation(s)
- Jurij Hanzel
- Department of Gastroenterology, Faculty of Medicine, University of Ljubljana, Ljubljana, 1000, Slovenia
- Alimentiv Inc, London, Ontario, N6A 5B6, Canada
| | - Christopher Ma
- Alimentiv Inc, London, Ontario, N6A 5B6, Canada
- Departments of Medicine & Community Health Sciences, Division of Gastroenterology & Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada
| | - Vipul Jairath
- Alimentiv Inc, London, Ontario, N6A 5B6, Canada
- Schulich School of Medicine & Dentistry, Western University, London, Ontario, N6A 5C1, Canada
- Department of Epidemiology & Biostatistics, Western University, London, Ontario, N6G 2M1, Canada
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Singh A, Midha V, Kochhar GS, Shen B, Sood A. Management of Perianal Fistulizing Crohn's Disease. Inflamm Bowel Dis 2023:izad195. [PMID: 37672347 DOI: 10.1093/ibd/izad195] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Indexed: 09/08/2023]
Abstract
Perianal fistulizing Crohn's disease (CD) represents a severe phenotype of CD that is associated with significant morbidity and reduction in quality of life. Perianal fistulizing CD is caused by a complex interplay of genetic predisposition, immune dysregulation, gut dysbiosis, and various unknown physiological and mechanical factors. A multidisciplinary approach is hence required for optimal management . A detailed anatomical description and classification of perianal fistula, including comprehensive clinical, endoscopic, and radiological diagnostic workup, is an important prerequisite to treatment. For simple perianal fistulas, use of antibiotics and immunomodulators, with or without fistulotomy, are appropriate measures. The medical management of complex perianal fistula, on the other hand, requires adequate control of infection before initiation of therapy with immunomodulators. In active complex perianal fistula, anti-tumor necrosis factors remain the most accepted therapy, with concomitant use of antibiotics or immunomodulators enhancing the efficacy. For patients refractory to anti-tumor necrosis factors, treatment with anti-integrins, anti-interleukins, and small molecules is being evaluated. Mesenchymal stem cells, hyperbaric oxygen therapy, and exclusive enteral nutrition have also been investigated as adjunct therapies. Despite the expansion of the medical armamentarium, a large proportion of the patients require surgical interventions. In this review, we provide an up-to-date overview of the pathophysiology, clinical presentation, diagnosis, and medical management of perianal fistulizing CD. A brief overview of the surgical management of perianal fistulizing CD is also provided.
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Affiliation(s)
- Arshdeep Singh
- Department of Gastroenterology, Dayanand Medical College, Ludhiana, India
| | - Vandana Midha
- Department of Internal Medicine, Dayanand Medical College, Ludhiana, India
| | - Gursimran Singh Kochhar
- Division of Gastroenterology, Hepatology and Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
| | - Bo Shen
- Center for Interventional Inflammatory Bowel Disease, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Ajit Sood
- Department of Gastroenterology, Dayanand Medical College, Ludhiana, India
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Huang K, Liu J, Xia W, Tian C, Yao L, Cao Q, Chen H. Effectiveness and safety of vedolizumab for ulcerative colitis: a single-center retrospective real-world study in China. Front Pharmacol 2023; 14:1188751. [PMID: 37214457 PMCID: PMC10192573 DOI: 10.3389/fphar.2023.1188751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 04/24/2023] [Indexed: 05/24/2023] Open
Abstract
Introduction: The effectiveness and safety of vedolizumab (VDZ) against ulcerative colitis (UC) have been validated in several randomized controlled trials and real-world studies in Western countries. However, there are few studies on VDZ in Asia, and the follow-up period for these studies is generally short. Therefore, this study evaluates the long-term effectiveness and safety of VDZ in Chinese patients with UC. Methods: This retrospective study included patients with moderate to severe UC treated with VDZ between September 2019 and April 2022 at Sir Run Run Shaw Hospital, College of Medicine Zhejiang University. Clinical response and remission were assessed using the patient reported outcomes and the partial Mayo Score, and mucosal remission and healing were assessed using the Mayo Endoscopy Score. The primary endpoint was defined as clinical remission at week 14, and secondary endpoints included clinical response and steroid-free clinical remission at week 14, clinical response, clinical remission, and steroid-free clinical remission at week 52, and mucosal remission and healing at weeks 14 ± 8 and 52 ± 8. Results: Overall, 64 patients with moderate to severe UC were enrolled. The clinical response, clinical remission, and steroid-free clinical remission rates at week 14 were 73.4% (47/64), 65.6% (42/64), and 54.7% (35/64), respectively. Mucosal remission and healing rates at week 14 ± 8 were 64.7% (22/34) and 38.2% (13/34), respectively. A total of 48 patients were treated with VDZ for 52 weeks. Based on intention-to-treat analysis, the clinical response, clinical remission, and steroid-free clinical remission rates at week 52 were 68.8% (44/64), 64.1% (41/64), and 64.1% (41/64), respectively. Mucosal remission and healing rates at week 52 ± 8 were 70.6% (12/17) and 35.3% (6/17), respectively. During the follow-up period, the most common adverse event was skin rash (6/64). No cases of acute infusion reactions, delayed allergic reactions, new hepatitis B infections, active tuberculosis, or malignant tumors were reported. Conclusion: In this single-center retrospective real-world study, the effectiveness of long-term use of VDZ for Chinese patients with UC was similar to the outcomes previously reported in other geographical regions and populations; no new safety signals were found compared with other registered studies.
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Affiliation(s)
- Kaituo Huang
- Department of Gastroenterology, Sir Run Run Shaw Hospital, College of Medicine Zhejiang University, Hangzhou, China
- Inflammatory Bowel Disease Center of Sir Run Run Shaw Hospital, College of Medicine Zhejiang University, Hangzhou, China
| | - Jing Liu
- Department of Gastroenterology, Sir Run Run Shaw Hospital, College of Medicine Zhejiang University, Hangzhou, China
- Inflammatory Bowel Disease Center of Sir Run Run Shaw Hospital, College of Medicine Zhejiang University, Hangzhou, China
| | - Wenhao Xia
- Department of Gastroenterology, Sir Run Run Shaw Hospital, College of Medicine Zhejiang University, Hangzhou, China
- Inflammatory Bowel Disease Center of Sir Run Run Shaw Hospital, College of Medicine Zhejiang University, Hangzhou, China
| | - Chuwen Tian
- Department of Gastroenterology, Sir Run Run Shaw Hospital, College of Medicine Zhejiang University, Hangzhou, China
- Inflammatory Bowel Disease Center of Sir Run Run Shaw Hospital, College of Medicine Zhejiang University, Hangzhou, China
| | - Lingya Yao
- Department of Gastroenterology, Sir Run Run Shaw Hospital, College of Medicine Zhejiang University, Hangzhou, China
- Inflammatory Bowel Disease Center of Sir Run Run Shaw Hospital, College of Medicine Zhejiang University, Hangzhou, China
| | - Qian Cao
- Department of Gastroenterology, Sir Run Run Shaw Hospital, College of Medicine Zhejiang University, Hangzhou, China
- Inflammatory Bowel Disease Center of Sir Run Run Shaw Hospital, College of Medicine Zhejiang University, Hangzhou, China
| | - Haotian Chen
- Department of Gastroenterology, Sir Run Run Shaw Hospital, College of Medicine Zhejiang University, Hangzhou, China
- Inflammatory Bowel Disease Center of Sir Run Run Shaw Hospital, College of Medicine Zhejiang University, Hangzhou, China
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9
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Solitano V, Ma C, Hanžel J, Panaccione R, Feagan BG, Jairath V. Advanced Combination Treatment With Biologic Agents and Novel Small Molecule Drugs for Inflammatory Bowel Disease. Gastroenterol Hepatol (N Y) 2023; 19:251-263. [PMID: 37799456 PMCID: PMC10548249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
The use of combination therapy with a biologic agent and immunosuppressant has well-established efficacy and safety and is common practice in the management of inflammatory bowel disease (IBD). Current research has shifted focus toward the use of advanced combination treatment (ACT). This term was coined to describe combination therapy using 2 or more advanced treatments (biologic agents and/or oral small molecule drugs) with the aim of achieving optimal disease control in selected patients. An ACT approach may be particularly beneficial in patients with documented medically refractory IBD and in patients with a poor prognosis, extraintestinal manifestations, or concomitant immune-mediated inflammatory diseases. To date, the body of evidence for ACT strategies in IBD is largely comprised of uncontrolled retrospective case series and cohort studies in highly refractory patients. Recently, results from the VEGA trial have suggested that combination induction therapy with guselkumab and golimumab was more effective in ulcerative colitis than either agent alone. However, questions remain about issues such as related costs, ACT duration, and optimal combinations to adopt. Future randomized controlled trials are likely to evaluate rationally selected combinations of agents. This article summarizes the available literature on ACT, including comparisons with traditional combination therapy and the rheumatology field, and discusses practical recommendations, profiles of IBD patients who should be considered for combination approaches in clinical practice, and remaining knowledge gaps.
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Affiliation(s)
- Virginia Solitano
- Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada
- Alimentiv, London, Ontario, Canada
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Christopher Ma
- Alimentiv, London, Ontario, Canada
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jurij Hanžel
- Alimentiv, London, Ontario, Canada
- Department of Gastroenterology and Hepatology, University Medical Center Ljubljana and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Remo Panaccione
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brian G. Feagan
- Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada
- Alimentiv, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Vipul Jairath
- Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada
- Alimentiv, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
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10
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McCormack MD, Wahedna NA, Aldulaimi D, Hawker P. Emerging role of dual biologic therapy for the treatment of inflammatory bowel disease. World J Clin Cases 2023; 11:2621-2630. [PMID: 37214562 PMCID: PMC10198105 DOI: 10.12998/wjcc.v11.i12.2621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 02/07/2023] [Accepted: 03/24/2023] [Indexed: 04/25/2023] Open
Abstract
Biologic agents have now been used in the management of inflammatory bowel disease (IBD) for many years where experience, expertise and confidence in their use has developed over time. In the United Kingdom, there are well established guidelines and recommendations for both single agent biologic treatments, and with combination therapy of a biologic agent with a small molecule agent in maintenance therapy. In recent times, there has been increasing interest and experience using dual biologic therapy (DBT) in IBD, primarily in difficult to treat and refractory cases with high disease burden. However, published data on use, experience and safety profiles is limited and large-scale studies remain low in number in this developing area. We therefore aim to present a summary and review of the available published data in this area to help us better understand the emerging role of DBT in IBD.
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Affiliation(s)
- Matthew D McCormack
- Department of Gastroenterology, South Warwickshire NHS Foundation Trust, Warwick Hospital, Warwick CV34 5BW, United Kingdom
| | - Natasha A Wahedna
- Department of Gastroenterology, South Warwickshire NHS Foundation Trust, Warwick Hospital, Warwick CV34 5BW, United Kingdom
| | - David Aldulaimi
- Department of Gastroenterology, South Warwickshire NHS Foundation Trust, Warwick Hospital, Warwick CV34 5BW, United Kingdom
| | - Peter Hawker
- Department of Gastroenterology, South Warwickshire NHS Foundation Trust, Warwick Hospital, Warwick CV34 5BW, United Kingdom
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11
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Khoshnam-Rad N, Vahedi H, Sadeghi A, Rastegarpanah M, Namazi S, Anushiravani A, Sima AR, Shahrokh S, Alatab S, Malekzadeh R. Iranian Consensus Guideline for Pharmacotherapy with Biologics and Small Molecules Drugs in Adults with Inflammatory Bowel Diseases. Middle East J Dig Dis 2023; 15:83-106. [PMID: 37546508 PMCID: PMC10404092 DOI: 10.34172/mejdd.2023.327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 02/11/2023] [Indexed: 08/08/2023] Open
Abstract
Background: Pharmacotherapy with biologics and small molecules, as the more effective therapies for moderate to severe ulcerative colitis (UC) and Crohn's disease (CD), is complex. Choosing the best methods for their utilization in order to induce and maintain remission are critical for practicing gastroenterologists. We aimed to develop an Iranian consensus on the management of inflammatory bowel disease (IBD) patients with biologics and small molecules. Methods: A Delphi consensus was undertaken by experts who performed a literature summary and voting process. Quality of evidence was assessed using the Grading and Recommendations Assessment, Development, and Evaluation; and an additional risk of bias-protocol. Results: Following an extensive search of the literature, 219 studies were used to determine the quality of the evidence. After three rounds of voting, consensus (defined as≥80% agreement) was reached for 87 statements. Conclusion: We considered different aspects of pharmacotherapy in this consensus. This guideline, along with clinical judgment, can be used to optimize management of IBD patients.
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Affiliation(s)
- Niloofar Khoshnam-Rad
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Homayoon Vahedi
- Digestive Disease Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Anahita Sadeghi
- Digestive Disease Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mansoor Rastegarpanah
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Soha Namazi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Anushiravani
- Digestive Disease Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Reza Sima
- Sasan Alborz Biomedical Research Center, Masoud Gastroenterology and Hepatology Center, Tehran, Iran
| | - Shabnam Shahrokh
- Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sudabeh Alatab
- Digestive Disease Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Malekzadeh
- Digestive Disease Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
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12
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Cheah E, Huang JG. Precision medicine in inflammatory bowel disease: Individualizing the use of biologics and small molecule therapies. World J Gastroenterol 2023; 29:1539-1550. [PMID: 36970587 PMCID: PMC10037250 DOI: 10.3748/wjg.v29.i10.1539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 01/17/2023] [Accepted: 02/22/2023] [Indexed: 03/14/2023] Open
Abstract
The advent of biologics and small molecules in inflammatory bowel disease (IBD) has marked a significant turning point in the prognosis of IBD, decreasing the rates of corticosteroid dependence, hospitalizations and improving overall quality of life. The introduction of biosimilars has also increased affordability and enhanced access to these otherwise costly targeted therapies. Biologics do not yet represent a complete panacea: A subset of patients do not respond to first-line anti-tumor necrosis factor (TNF)-alpha agents or may subsequently demonstrate a secondary loss of response. Patients who fail to respond to anti-TNF agents typically have a poorer response rate to second-line biologics. It is uncertain which patient would benefit from a different sequencing of biologics or even a combination of biologic agents. The introduction of newer classes of biologics and small molecules may provide alternative therapeutic targets for patients with refractory disease. This review examines the therapeutic ceiling in current treatment strategies of IBD and the potential paradigm shifts in the future.
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Affiliation(s)
- Eric Cheah
- Department of Gastroenterology and Clinical Nutrition, The Royal Children's Hospital Melbourne, Parkville, VIC 3052, Australia
| | - James Guoxian Huang
- Department of Paediatrics, Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore 119228, Singapore
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
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13
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Cheah E, Huang JG. Precision medicine in inflammatory bowel disease: Individualizing the use of biologics and small molecule therapies. World J Gastroenterol 2023; 29:1395-1406. [DOI: 10.3748/wjg.v29.i10.1395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2023] Open
Abstract
The advent of biologics and small molecules in inflammatory bowel disease (IBD) has marked a significant turning point in the prognosis of IBD, decreasing the rates of corticosteroid dependence, hospitalizations and improving overall quality of life. The introduction of biosimilars has also increased affordability and enhanced access to these otherwise costly targeted therapies. Biologics do not yet represent a complete panacea: A subset of patients do not respond to first-line anti-tumor necrosis factor (TNF)-alpha agents or may subsequently demonstrate a secondary loss of response. Patients who fail to respond to anti-TNF agents typically have a poorer response rate to second-line biologics. It is uncertain which patient would benefit from a different sequencing of biologics or even a combination of biologic agents. The introduction of newer classes of biologics and small molecules may provide alternative therapeutic targets for patients with refractory disease. This review examines the therapeutic ceiling in current treatment strategies of IBD and the potential paradigm shifts in the future.
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Affiliation(s)
- Eric Cheah
- Department of Gastroenterology and Clinical Nutrition, The Royal Children's Hospital Melbourne, Parkville, VIC 3052, Australia
| | - James Guoxian Huang
- Department of Paediatrics, Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore 119228, Singapore,Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
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14
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Danese S. Combining Mechanisms of Action to Treat Patients With Inflammatory Bowel Disease. Gastroenterol Hepatol (N Y) 2023; 19:31-33. [PMID: 36865814 PMCID: PMC9972657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Affiliation(s)
- Silvio Danese
- Director, Gastroenterology and Endoscopy IRCCS Ospedale San Raffaele Professor of Gastroenterology University Vita-Salute San Raffaele Milan, Italy
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15
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Balderramo D. Role of the combination of biologics and/or small molecules in the treatment of patients with inflammatory bowel disease. World J Gastroenterol 2022; 28:6743-6751. [PMID: 36620336 PMCID: PMC9813940 DOI: 10.3748/wjg.v28.i47.6743] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/26/2022] [Accepted: 11/27/2022] [Indexed: 12/19/2022] Open
Abstract
Inflammatory bowel disease (IBD) is a group of chronic diseases that includes ulcerative colitis, Crohn’s disease, and indeterminate colitis. Patients with IBD require prolonged treatment and high utilization of healthcare resources for proper management. The treatment of patients with IBD is focused on achieving therapeutic goals including clinical, biochemical, and endoscopic variables that result in improvement of the quality of life and prevention of disability. Advanced IBD treatment includes tumor necrosis factor inhibitors, integrin antagonist, antagonist of the p40 subunit of interleukin 12/23, and small molecule drugs. However, despite the multiple treatments available, about 40% of patients are refractory to therapy and present with persistent symptoms that have a great impact on their quality of life, with hospitalization and surgery being necessary in many cases. Dual therapy, a strategy sometimes applicable to refractory IBD patients, includes the combination of two biologics or a biologic in combination with a small molecule drug. There are two distinct scenarios in IBD patients in which this approach can be used: (1) Refractory active luminal disease without extraintestinal manifestations; and (2) patients with IBD in remission, but with active extraintestinal manifestations or immune-mediated inflammatory diseases. This review provides a summary of the results (clinical response and remission) of different combinations of advanced drugs in patients with IBD, both in adults and in the pediatric population. In addition, the safety profile of different combinations of dual therapy is analyzed. The use of newer combinations, including recently approved treatments, the application of new biomarkers and artificial intelligence, and clinical trials to establish effectiveness during long-term follow-up, are needed to establish new strategies for the use of advanced treatments in patients with refractory IBD.
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Affiliation(s)
- Domingo Balderramo
- Department of Gastroenterology, Hospital Privado Universitario de Córdoba, Instituto Universitario de Ciencias Biomédicas de Córdoba, Córdoba 5016, Argentina
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16
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Danese S, Solitano V, Jairath V, Peyrin-Biroulet L. The future of drug development for inflammatory bowel disease: the need to ACT (advanced combination treatment). Gut 2022; 71:2380-2387. [PMID: 35701092 DOI: 10.1136/gutjnl-2022-327025] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 06/02/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Silvio Danese
- Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milano, Italy
| | - Virginia Solitano
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Vipul Jairath
- Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada.,Alimentiv, London, Ontario, Canada
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17
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Abdullah I, AlMojil K, Shehab M. Effectiveness of Dual Biologic or Small Molecule Therapy for Achieving Endoscopic Remission in Refractory Inflammatory Bowel Disease. Diseases 2022; 10:diseases10040102. [PMID: 36412596 PMCID: PMC9680431 DOI: 10.3390/diseases10040102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 10/06/2022] [Accepted: 11/02/2022] [Indexed: 11/12/2022] Open
Abstract
Inflammatory bowel disease (IBD) is a chronic autoimmune disease with relapse-remission courses. A number of patients may present with a refractory disease with partial or no response to treatment. Others may present with extra-intestinal manifestations that makes the treatment with one biologic challenging. Dual target therapy (DTT), combining biologics and/or small molecule drugs, may offer a chance to achieve remission in these cases and improve patients' quality of life despite the limited evidence regarding this approach. We present a case series of refractory inflammatory bowel disease cases managed with DTT. Seven patients with refractory IBD achieved steroid free, clinical, and endoscopic remission by using DTT. These results support that DTT could be an effective approach in selected patients with refractory IBD or with concomitant extra-intestinal manifestations (EIM). Larger studies, ideally randomized controlled trials, are needed to further support the evidence and confirm the efficacy and safety of DTT for IBD.
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Affiliation(s)
- Israa Abdullah
- Department of Pharmacy, Clinical Pharmacy Unit, Kuwait Hospital, Sabah Al-Salem 44001, Kuwait
| | - Khaled AlMojil
- Division of Gastroenterology, Department of Internal Medicine, Mubarak Alkabeer University Hospital, Kuwait University, Jabriya 47060, Kuwait
| | - Mohammad Shehab
- Division of Gastroenterology, Department of Internal Medicine, Mubarak Alkabeer University Hospital, Kuwait University, Jabriya 47060, Kuwait
- Correspondence: ; Tel.: +965-99633181
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18
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Vuyyuru SK, Kedia S, Ahuja V. Considerations when starting patients on multiple biologics and small molecules. Curr Opin Gastroenterol 2022; 38:562-569. [PMID: 36165042 DOI: 10.1097/mog.0000000000000886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE OF REVIEW Inflammatory bowel disease (IBD) is complex disease that poses significant economic, and psychological burden on patients. Despite advent of newer biologics and small molecules targeting different aspects of immunopathogenesis, there appears to be a plateau in clinical outcomes. In this review we discuss the role of multiple biologics, existing evidence and various considerations when prescribing multiple biologics. RECENT FINDINGS Recent scientific advances helped to unravel the pathophysiology of inflammatory bowel disease and newer cytokines have been identified which can be potential targets in the management of IBD. Targeting more than one cytokine appears to be logical solution to break the therapeutic ceiling to improve clinical outcomes in IBD. The combination biologics appear safe and effective; however, the available evidence is limited. Refractory IBD, presence of other immune mediated inflammatory diseases and extra intestinal manifestations are currently the common considerations of combination biologics in IBD. SUMMARY Inflammatory bowel disease is a complex immune mediated disease with diverse clinical presentation and often has a complicated clinical course requiring multidisciplinary management. As the number of targeted therapies increases so does the concern on their safety and efficacy. Combination biologics though may appear to be safe, we need well designed prospective studies for firm conclusions.
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Affiliation(s)
- Sudheer K Vuyyuru
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
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19
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Uzzan M. Tofacitinib: A Small Molecule for Biologic-Refractory Crohn's Disease? Dig Dis Sci 2022; 67:3479-3480. [PMID: 35288832 DOI: 10.1007/s10620-022-07448-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/09/2022] [Indexed: 12/09/2022]
Affiliation(s)
- Mathieu Uzzan
- Gastroenterology Department, Henri Mondor Hospital and Paris Est Créteil University UPEC, Assistance Publique-Hôpitaux de Paris (AP-HP), Fédération Hospitalo-Universitaire TRUE (InnovaTive theRapy for immUne disordErs), 94010, Créteil, France.
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20
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Abstract
PURPOSE OF REVIEW Nearly one-third of patients with inflammatory bowel disease (IBD) do not achieve remission despite our best therapies. When this happens, it is critical to understand the reason for treatment failure. Once nonresponse is confirmed, these patients should be referred to an IBD centre for multidisciplinary care. This review will discuss the remaining treatment options, including escalation of biologics to unlicensed doses, combination biologics, nonvalidated therapies and surgical options. It will additionally provide updates in the management of acute severe ulcerative colitis (ASUC). RECENT FINDINGS There is an increasing interest in combination biologics to treat refractory IBD, although data supporting its safety and effectiveness are limited. The use of hyperbaric oxygen, mesenchymal stem cell therapy and dietary interventions also show early promise in this area. Studies have additionally focused on personalized therapy to identify aggressive phenotypes and predict treatment response in these challenging patients. In ASUC, infliximab and cyclosporine remain mainstays of treatment, and tofacitinib shows promise as a salvage therapy. SUMMARY Refractory IBD is common, yet large knowledge gaps remain. Recent and ongoing studies have focused on medical, surgical and dietary approaches with mixed success. Larger prospective studies are desperately needed to address this complex issue.
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21
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The Optimal Management of Fistulizing Crohn’s Disease: Evidence beyond Randomized Clinical Trials. J Clin Med 2022; 11:jcm11113045. [PMID: 35683433 PMCID: PMC9181669 DOI: 10.3390/jcm11113045] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/21/2022] [Accepted: 05/25/2022] [Indexed: 02/04/2023] Open
Abstract
Fistulizing Crohn’s disease (FCD) remains the most challenging aspect of treating patients with CD. FCD can occur in up to 30% of patients with CD and may lead to significant disability and impaired quality of life. The optimal treatment strategies for FCD require a multidisciplinary approach, including a combined medical and surgical approach. The therapeutic options for FCD are limited due to sparse evidence from randomized clinical trials (RCTs). The current recommendations are mainly based on post hoc analysis from RCTs, real-world clinical studies and expert opinion. There is variation in everyday clinical practice amongst gastroenterologists and surgeons. The evidence for anti-tumor necrosis factor therapy is the strongest in the treatment of FCD. However, long-term fistula healing can be achieved in only 30–50% of patients. In recent years, emerging data in the advent of therapeutic modalities, including the use of new biologic agents, therapeutic drug monitoring, novel surgical methods and mesenchymal stem cell therapy, have been shown to improve outcomes in achieving fistula healing. This review summarizes the existing literature on current and emerging therapies to provide guidance beyond RCTs in managing FCD.
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22
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Hanzel J, Hulshoff MS, Grootjans J, D'Haens G. Emerging therapies for ulcerative colitis. Expert Rev Clin Immunol 2022; 18:513-524. [PMID: 35477319 DOI: 10.1080/1744666x.2022.2069562] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Despite advances in the medical management of ulcerative colitis (UC), a subgroup of patients does not respond to currently available therapies. A number of novel drugs are in late stages of clinical development or have recently received regulatory approval for UC. AREAS COVERED This review focuses on three drug classes that have recently been approved or are awaiting approval for UC: antibodies against interleukin (IL)-23, sphingosine-1-phosphate receptor (S1PR) modulators, and selective inhibitors of Janus kinases (JAK). We provide an overview of their mechanism of action and summarize available evidence for their efficacy and safety. Finally, we discuss expected future challenges in UC management. EXPERT OPINION The evaluated drugs have demonstrated efficacy with an acceptable safety profile. IL-23 antagonists appear to be safest with very few (serious) adverse events, while the use of S1PR modulators or JAK inhibitors has been associated with infectious and cardiovascular/thromboembolic events, albeit in low numbers. Although advances in drug development are promising, there is an urgent need for (validated) biomarkers to guide rational treatment selection. The scarcity of head-to-head trials also complicates comparisons between available drugs. Breaking the therapeutic ceiling of efficacy in UC will require marked advances in management extending well beyond drug development.
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Affiliation(s)
- Jurij Hanzel
- Faculty of Medicine, University of Ljubljana, Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Melanie S Hulshoff
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, Academic Medical Centre, Amsterdam, the Netherlands
| | - Joep Grootjans
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, Academic Medical Centre, Amsterdam, the Netherlands
| | - Geert D'Haens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, Academic Medical Centre, Amsterdam, the Netherlands
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23
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Targeting the endo-lysosomal autophagy pathway to treat inflammatory bowel diseases. J Autoimmun 2022; 128:102814. [PMID: 35298976 DOI: 10.1016/j.jaut.2022.102814] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/03/2022] [Accepted: 03/04/2022] [Indexed: 01/18/2023]
Abstract
Inflammatory bowel disease (IBD) is a serious public health problem in Western society with a continuing increase in incidence worldwide. Safe, targeted medicines for IBD are not yet available. Autophagy, a vital process implicated in normal cell homeostasis, provides a potential point of entry for the treatment of IBDs, as several autophagy-related genes are associated with IBD risk. We conducted a series of experiments in three distinct mouse models of colitis to test the effectiveness of therapeutic P140, a phosphopeptide that corrects autophagy dysfunctions in other autoimmune and inflammatory diseases. Colitis was experimentally induced in mice by administering dextran sodium sulfate and 2,4,6 trinitrobenzene sulfonic acid. Transgenic mice lacking both il-10 and iRhom2 - involved in tumor necrosis factor α secretion - were also used. In the three models investigated, P140 treatment attenuated the clinical and histological severity of colitis. Post-treatment, altered expression of several macroautophagy and chaperone-mediated autophagy markers, and of pro-inflammatory mediators was corrected. Our results demonstrate that therapeutic intervention with an autophagy modulator improves colitis in animal models. These findings highlight the potential of therapeutic peptide P140 for use in the treatment of IBD.
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24
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Mas EB, Calvo XC. Selecting the Best Combined Biological Therapy for Refractory Inflammatory Bowel Disease Patients. J Clin Med 2022; 11:jcm11041076. [PMID: 35207347 PMCID: PMC8877715 DOI: 10.3390/jcm11041076] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/13/2022] [Accepted: 02/16/2022] [Indexed: 02/07/2023] Open
Abstract
Current medical treatment for inflammatory bowel disease (IBD) does not achieve 100% response rates, and a subset of refractory and severely ill patients have persistent active disease after being treated with all possible drug alternatives. The combination of two biological therapies (CoT) seems a reasonable alternative, and has been increasingly tested in very difficult cases. The present review suggests that CoT seems to be safe and effective for refractory and severely ill IBD patients. Ustekinumab plus vedolizumab and vedolizumab plus anti-TNF were the most used CoTs for Crohn’s disease. For ulcerative colitis, the most used CoTs were vedolizumab plus anti-TNF and vedolizumab plus tofacitinib. The aforesaid CoTs have shown good efficacy and few adverse events have been reported.
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Affiliation(s)
- Eduard Brunet Mas
- Servei Aparell Digestiu, Hospital Universitari Parc Taulí, 08208 Sabadell, Spain;
- Departament de Medicina, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
- CIBERehd, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Xavier Calvet Calvo
- Servei Aparell Digestiu, Hospital Universitari Parc Taulí, 08208 Sabadell, Spain;
- Departament de Medicina, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
- CIBERehd, Instituto de Salud Carlos III, 28029 Madrid, Spain
- Correspondence: ; Tel.: +34-937231010 (ext. 20111)
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25
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Pawlak KM, Wauters L. Guidelines, top-notch science & social media-Jump on the bandwagon. United European Gastroenterol J 2022; 10:12-14. [PMID: 35088535 PMCID: PMC8830269 DOI: 10.1002/ueg2.12203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Katarzyna M Pawlak
- Endoscopy Unit, Department of Gastroenterology, Hospital of the Ministry of Interior and Administration, Szczecin, Poland
| | - Lucas Wauters
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
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