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Song JH, Hong SN, Kim MG, Kim M, Kim SK, Kim ER, Chang DK, Kim YH. Population Pharmacokinetic Model for the Use of Intravenous or Subcutaneous Infliximab in Patients with Inflammatory Bowel Disease: Real-World Data from a Prospective Cohort Study. Gut Liver 2025; 19:376-387. [PMID: 40254990 PMCID: PMC12070208 DOI: 10.5009/gnl240503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2024] [Revised: 02/03/2025] [Accepted: 02/04/2025] [Indexed: 04/22/2025] Open
Abstract
Background/Aims Infliximab treatment failure in patients with inflammatory bowel disease may result from sub-optimal infliximab trough level. An understanding of pharmacokinetics (PKs) is important to maintain an optimal trough level. PK studies of the switch to subcutaneous (SC) infliximab from intravenous (IV) infliximab using real-world data are lacking. We aimed to develop a population PK model of IV and SC infliximab to predict individual infliximab exposure during maintenance therapy. Methods We used data from prospectively collected data on IV and SC infliximab concentrations in patients with inflammatory bowel disease receiving maintenance treatment from February 2020 to December 2022 at Samsung Medical Center. Population PK analysis was conducted by using a two-compartment model with first-order absorption and first-order elimination. Goodness-of-fit plots and visual predictive check were used to evaluate the PK model. Results A total of 2,132 samples from 181 patients (149 Crohn's disease and 32 ulcerative colitis) were analyzed. We developed an infliximab population PK model using body mass index, albumin, C-reactive protein level, and the anti-drug antibody level and validated its predictive performance. Conclusions It may be possible to predict the infliximab trough level of both IV and SC infliximab in patients with inflammatory bowel disease during maintenance treatment by using our model in real-world practice.
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Affiliation(s)
- Joo Hye Song
- Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Sung Noh Hong
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Myeong Gyu Kim
- College of Pharmacy, Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Korea
| | - Minjung Kim
- College of Pharmacy, Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Korea
| | - Seong Kyung Kim
- College of Pharmacy, Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Korea
| | - Eun Ran Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Kyung Chang
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young-Ho Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Sharma K, da Silva BC, Hanauer SB. The role of immunogenicity in optimizing biological therapies for inflammatory bowel disease. Expert Rev Gastroenterol Hepatol 2025:1-16. [PMID: 39964309 DOI: 10.1080/17474124.2025.2468302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2024] [Revised: 02/07/2025] [Accepted: 02/13/2025] [Indexed: 02/26/2025]
Abstract
INTRODUCTION Immunogenicity of biologic agents for inflammatory bowel disease (IBD) is a critical issue, especially for tumor necrosis factor (TNF) inhibitors, where anti-drug antibodies (ADAs) significantly impact drug clearance, efficacy, and safety. Studies have demonstrated that non-TNF biologics tend to have lower susceptibility to immunogenicity, potentially offering advantages, especially in long-term management. Understanding these differences is important for optimizing IBD treatment outcomes. AREAS COVERED This review examines immunogenicity associated with different classes and individual biologic agents used in IBD; including TNF inhibitors and biologics targeting integrins and interleukins. We discuss key factors influencing ADAs formation, including drug structure, route of administration, and patient-specific factors. The literature reviewed includes recent clinical studies and long-term trials focusing on strategies to reduce immunogenicity such as therapeutic drug monitoring (TDM) and advanced combination. EXPERT OPINION While newer biologics demonstrate lower immunogenicity compared to anti-TNF agents, challenges remain in management to overcome existing ADAs responses while advances in genetic profiling, point-of-care TDM, and combination therapies offer promising pathways to reduce immunogenicity and enhance treatment durability. Continued research and innovation in biologic delivery methods, such as oral and subcutaneous formulations, will be critical in the next decade to further mitigate immunogenic risks and improve patient outcomes.
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Affiliation(s)
| | | | - Stephen B Hanauer
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Jin X, Sun K, Wang L, Shen H, Ma D, Shen T, Chen C, Li L. Efficacy and safety of dual-targeted therapy for inflammatory bowel disease: a retrospective multicenter study in China. Therap Adv Gastroenterol 2025; 18:17562848241307598. [PMID: 39758966 PMCID: PMC11696958 DOI: 10.1177/17562848241307598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2024] [Accepted: 11/29/2024] [Indexed: 01/07/2025] Open
Abstract
Background Treatment options for patients with refractory inflammatory bowel disease (IBD) or concomitant IBD and extraintestinal manifestations (EIM) are often limited. Objective This study aimed to examine the efficacy and safety of combining biologics or small molecules in patients with refractory IBD, active EIM, or active immune-mediated inflammatory disease (IMID). Design This was a retrospective and multicenter study. Methods We retrospectively collected demographics and disease characteristics from 47 patients with IBD who received dual-targeted therapy in 3 hospitals from January 2022 to June 2024. The primary endpoint was clinical remission based on the Harvey-Bradshaw index or patient-reported outcome 2 after at least 4 months of combination therapy. The secondary endpoints included clinical response, endoscopic response, and endoscopic remission, as well as all adverse events that occurred within the period of combination therapy. Results In total, 47 IBD patients including 37 with refractory IBD, 5 with active EIM, and 5 with active IMID received dual-targeted therapy, of which 37 achieved clinical response (78.7%) and 27 achieved clinical remission (57.4%) at a median follow-up time of 13.0 months. Among these 47 patients, 29 patients underwent endoscopic follow-up, of which 15 (51.7%) achieved endoscopic response and 8 (27.6%) achieved endoscopic remission at a median follow-up time of 9.0 months. Mild and moderate adverse events were reported in 17 (36.2%) patients within the period of combination therapy, and serious adverse events requiring hospitalization occurred in 1 patient (2.1%). Conclusion The combination therapy of biologics and small molecules for refractory IBD or those with concomitant EIM/IMID is effective and safe.
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Affiliation(s)
- Xiuxiu Jin
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang University, Hangzhou, China
- Department of Gastroenterology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, Zhejiang, China
| | - Kefang Sun
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang University, Hangzhou, China
| | - Liying Wang
- Department of Gastroenterology, Shangyu People’s Hospital of Shaoxing, Shangyu, Zhejiang, China
| | - Haiyan Shen
- Department of Gastroenterology, The Second Hospital of Jiaxing, Jiaxing, Zhejiang, China
| | - Dan Ma
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang University, Hangzhou, China
| | - Tejia Shen
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang University, Hangzhou, China
| | - Chunxiao Chen
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou 310003, China
| | - Lan Li
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou 310003, China
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Nielsen OH, Hammerhøj A, Ainsworth MA, Gubatan J, D'Haens G. Immunogenicity of Therapeutic Antibodies Used for Inflammatory Bowel Disease: Treatment and Clinical Considerations. Drugs 2025; 85:67-85. [PMID: 39532820 DOI: 10.1007/s40265-024-02115-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2024] [Indexed: 11/16/2024]
Abstract
The introduction of tumor necrosis factor inhibitors has led to a paradigm shift in the management of inflammatory bowel disease (IBD). The subsequent introduction of both anti-integrins and cytokine blockers has since expanded the biologic armamentarium. However, immunogenicity, defined as the production of anti-drug antibodies (ADAs) to the prescribed biopharmaceutical, means a significant fraction of patients exposed to biologic agents will experience a secondary loss of response to one or more of the drugs. In clinical settings, immunogenicity may be caused by several factors, both patient related (e.g., underlying chronic disease, systemic immune burden, including previous biologic therapy failure, and [epi]genetic background) and treatment related (e.g., dose and administration regimens, drug physical structure, photostability, temperature, and agitation). Here, we outline these elements in detail to enhance biopharmaceutical delivery and therapy for patients with IBD. Moreover, concurrent immunomodulator medication may reduce the risks of ADA generation, especially when using the chimeric drug infliximab. Summarizing the latest developments and knowledge in the field, this review aims to provide strategies to prevent ADA production and information on managing non-responsiveness or loss of response to biologics. Better understanding of the molecular mechanisms underlying the formation of ADAs and the critical factors influencing the immunogenicity of biopharmaceuticals may lead to improved health outcomes in the IBD community that may benefit both the individual patient and society through lower healthcare expenses.
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Affiliation(s)
- Ole Haagen Nielsen
- Department of Gastroenterology D112, Herlev Hospital, University of Copenhagen, Borgmester Ib Juuls Vej 1, 2730 Herlev, Copenhagen, Denmark.
| | - Alexander Hammerhøj
- Department of Gastroenterology D112, Herlev Hospital, University of Copenhagen, Borgmester Ib Juuls Vej 1, 2730 Herlev, Copenhagen, Denmark
| | - Mark Andrew Ainsworth
- Department of Gastroenterology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - John Gubatan
- Department of Gastroenterology & Hepatology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Geert D'Haens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
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Tu T, Chen M, Zeng Z, Lin J, Chen L, Liu C, Zhuang X. A comprehensive review and update on acute severe lower gastrointestinal bleeding in Crohn's disease: a management algorithm. Gastroenterol Rep (Oxf) 2024; 12:goae099. [PMID: 39526201 PMCID: PMC11549058 DOI: 10.1093/gastro/goae099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 05/02/2024] [Accepted: 06/20/2024] [Indexed: 11/16/2024] Open
Abstract
Acute severe lower gastrointestinal bleeding is a rare but potentially fatal complication of Crohn's disease (CD), affecting between 0.6% and 5.5% of CD patients during their lifelong disease course. Managing bleeding episodes effectively hinges on vital resuscitation. Endoscopic evaluation and computed tomography play crucial roles in accurate identification and intervention. Fortunately, most bleeding episodes can be successfully managed through appropriate conservative treatment. Medical therapies, particularly infliximab, aim to induce and maintain mucosal healing and serve as the leading treatment approach. Minimally invasive procedures, such as endoscopic hemostasis and angio-embolization, can achieve immediate hemostasis. Surgical treatment is only considered a last resort when conservative therapies fail. Despite achieving hemostasis, the risk of rebleeding ranges from 19.0% to 50.5%. The objective of this review is to provide a comprehensive and updated overview of the clinical manifestations, diagnostic methods, therapeutic approaches, and prognostic outcomes associated with acute severe gastrointestinal bleeding in CD. Furthermore, we aimed to propose a management algorithm to assist clinicians in the effective management of this condition.
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Affiliation(s)
- Tong Tu
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Mengqi Chen
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Zhirong Zeng
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Jianming Lin
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Luohai Chen
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Caiguang Liu
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Xiaojun Zhuang
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
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Moses J, Adler J, Saeed SA, Firestine AM, Galanko JA, Ammoury RF, Bass DM, Bass JA, Bastidas M, Benkov KJ, Bousvaros A, Cabrera JM, Chun KY, Dorsey JM, Ebach DR, Gulati AS, Herfarth HH, Ivanova A, Jester TW, Kaplan JL, Kusek ME, Leibowitz IH, Linville TM, Margolis PA, Minar P, Molle-Rios Z, Niklinska-Schirtz BJ, Olano KK, Osaba L, Palomo PJ, Pashankar DS, Pitch L, Samson CM, Sandberg KC, Steiner SJ, Strople JA, Sullivan JS, Tung J, Wali P, Wohl DA, Zikry M, Boyle BM, Kappelman MD. Low Anti-Tumor Necrosis Factor Levels During Maintenance Phase Are Associated With Treatment Failure in Children With Crohn's Disease. Inflamm Bowel Dis 2024:izae239. [PMID: 39418336 DOI: 10.1093/ibd/izae239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Indexed: 10/19/2024]
Abstract
BACKGROUND Higher drug levels and combination therapy with low-dose oral methotrexate (LD-MTX) may reduce anti-tumor necrosis factor (TNF) treatment failure in pediatric Crohn's disease. We sought to (1) evaluate whether combination therapy with LD-MTX was associated with higher anti-TNF levels, (2) evaluate associations between anti-TNF levels and subsequent treatment failure, and (3) explore the effect of combination therapy on maintenance of remission among patients with therapeutic drug levels (>5 µg/mL for infliximab and >7.5 µg/mL for adalimumab). METHODS We conducted a post hoc analysis of the COMBINE trial, which compared anti-TNF monotherapy to combination therapy with LD-MTX. We included participants who entered maintenance therapy and provided a serum sample approximately 4 months from randomization. RESULTS Among 112 infliximab and 41 adalimumab initiators, median drug levels were similar between combination therapy and monotherapy (infliximab: 8.8 vs 7.5 μg/mL [P = .49]; adalimumab: 11.1 vs 10.5 μg/mL [P = .11]). Median drug levels were lower in patients experiencing treatment failure (infliximab: 4.2 vs 9.6 μg/mL [P < .01]; adalimumab: 9.1 vs 12.3 μg/mL [P < .01]). Among patients treated with infliximab with therapeutic drug levels, we observed no difference in treatment failure between participants assigned monotherapy or combination therapy. Among patients treated with adalimumab, a trend towards reduced treatment failure in the combination therapy arm was not statistically significant (P = .14). CONCLUSIONS LD-MTX combination was not associated with higher drug levels, but higher drug levels were associated with reduced risk of treatment failure. Among patients with therapeutic drug levels, we observed no benefit of LD-MTX for patients treated with infliximab. A nonsignificant trend towards reduced treatment failure with the addition of LD-MTX patients treated with adalimumab warrants further investigation.
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Affiliation(s)
- Jonathan Moses
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford Medicine Children's Health, Palo Alto, CA, USA
| | - Jeremy Adler
- Division of Gastroenterology, Hepatology, and Nutrition, C.S. Mott's Children's Hospital, Ann Arbor, MI, USA
- Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI, USA
| | - Shehzad A Saeed
- Department of Medical Affairs, Dayton Children's Hospital and Wright State University, Dayton, OH, USA
| | - Ann M Firestine
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Joseph A Galanko
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Rana F Ammoury
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children's Hospital of The King's Daughters, Norfolk, VA, USA
| | - Dorsey M Bass
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford Medicine Children's Health, Palo Alto, CA, USA
| | - Julie A Bass
- Department of Gastroenterology, Hepatology, and Nutrition, Children's Mercy Kansas City, Kansas City, MO, USA
| | | | - Keith J Benkov
- Division of Pediatric Gastroenterology, Icahn School of Medicine at Mt Sinai, New York, NY, USA
| | - Athos Bousvaros
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - José M Cabrera
- Division of Pediatric Gastroenterology, Department of Pediatrics, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kelly Y Chun
- Esoterix Specialty Laboratory, Labcorp, Calabasas, CA, USA
| | - Jill M Dorsey
- Pediatric Gastroenterology, Hepatology, and Nutrition, Nemours Children's Specialty Care, Jacksonville, FL, USA
| | - Dawn R Ebach
- Division of Pediatric Gastroenterology, Hepatology, Pancreatology, and Nutrition, Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Ajay S Gulati
- Department of Pediatrics and Pathology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Hans H Herfarth
- Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Anastasia Ivanova
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Traci W Jester
- Department of Pediatrics, Division of Gastroenterology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jess L Kaplan
- Division of Pediatric Gastroenterology, Mass General for Children and Harvard Medical School, Boston, MA, USA
| | - Mark E Kusek
- Division of Pediatric Gastroenterology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ian H Leibowitz
- Division of Gastroenterology, Hepatology and Nutrition, Children's National Medical Center, Department of Pediatrics, George Washington University, Washington, D.C., USA
| | - Tiffany M Linville
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Levine Children's Hospital, Charlotte, NC, USA
| | - Peter A Margolis
- Cincinnati Children's Research Foundation Chair in Improvement Science, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Phillip Minar
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Zarela Molle-Rios
- Division of Pediatric Gastroenterology, Nemours Children's Hospital, Wilmington, DE, USA
| | - Barbara Joanna Niklinska-Schirtz
- Division of Pediatric Gastroenterology, Department of Pediatrics, Emory University School of Medicine & Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Kelly K Olano
- Division of Biostatistics and Epidemiology, Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Lourdes Osaba
- Progenika Biopharma, a Grifols Company, Derio, Bizkaia, Spain
| | - Pablo J Palomo
- Division of Pediatric Gastroenterology, Nemours Children's Hospital, Orlando, FL, USA
| | - Dinesh S Pashankar
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Lisa Pitch
- ImproveCareNow Inc., Essex Junction, VT, USA
| | - Charles M Samson
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA
| | - Kelly C Sandberg
- Division of Gastroenterology, Hepatology, and Nutrition, Dayton Children's Hospital, Dayton, OH, USA
| | - Steven J Steiner
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jennifer A Strople
- Division of Gastroenterology, Hepatology and Nutrition, Ann and Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | - Jillian S Sullivan
- The University of Vermont Children's Hospital and Department of Pediatrics, Larner College of Medicine, The University of Vermont, Burlington, VT, USA
| | - Jeanne Tung
- University of Oklahoma Children's Physicians, Pediatric Gastroenterology, Oklahoma City, OK, USA
| | - Prateek Wali
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, State University of New York, Upstate Medical University, Syracuse, NY, USA
| | - David A Wohl
- Division of Infectious Diseases, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mike Zikry
- Esoterix Specialty Laboratory, Labcorp, Calabasas, CA, USA
| | - Brendan M Boyle
- Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, OH, USA
| | - Michael D Kappelman
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Ahuja D, Zou G, Solitano V, Syal G, Lee HH, Ma C, Jairath V, Singh S. No Impact of Concomitant Medications on Efficacy and Safety of Biologics and Small Molecules for Ulcerative Colitis. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00877-2. [PMID: 39395572 DOI: 10.1016/j.cgh.2024.08.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Revised: 08/10/2024] [Accepted: 08/22/2024] [Indexed: 10/14/2024]
Abstract
BACKGROUND & AIMS Although participants with inflammatory bowel diseases in clinical trials of biologics and small molecule drugs (henceforth, advanced therapies) frequently receive several medications concomitantly, it is unclear how they modify treatment effect. METHODS Through an individual patient data pooled analysis of 10 clinical trials of advanced therapies for moderate-to-severe ulcerative colitis, we assessed whether concomitant exposure to corticosteroids, immunomodulators, mesalamine, proton pump inhibitors, histamine receptor antagonists, opiates, antidepressants, and antibiotics modified the effect of the intervention on treatment efficacy and safety outcomes, using modified Poisson regression model. RESULTS Of 6044 patients (4280 receiving intervention, 1764 receiving placebo), several received concomitant corticosteroids (47%), immunomodulators (28%), mesalamine (68%), proton pump inhibitors (14%), histamine receptor antagonists (2%), opiates (7%), antidepressants (6%), and/or antibiotics (5%). After adjusting for confounders and examining treatment efficacy of intervention versus placebo, we observed no impact of concomitant exposure to corticosteroids (ratio of relative risk of drug vs placebo with vs without concomitant exposure: ratio of risk ratio [RRR], 0.81 [95% confidence interval, 0.63-1.06]), mesalamine (RRR, 1.04 [0.78-1.39]), proton pump inhibitors (RRR, 0.87 [0.61-1.22]), histamine receptor antagonists (RRR, 1.72 [0.97-14.29]), opiates (RRR, 0.90 [0.54-1.49]), antidepressants (RRR, 1.02 [0.57-1.83]), and antibiotics (RRR, 0.72 [0.44-1.16]) on likelihood of clinical remission. Concomitant exposure to immunomodulators was associated with lower likelihood of achieving clinical remission (RRR, 0.73 [0.55-0.97]), particularly with non-tumor necrosis factor antagonists. CONCLUSIONS In clinical trials of advanced therapies for ulcerative colitis, baseline concomitant exposure to multiple commonly used class of medications does not impact treatment efficacy or safety. These findings directly inform design of regulatory clinical trials with respect to managing concomitant medications at baseline.
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Affiliation(s)
- Dhruv Ahuja
- Department of Medicine, Indira Gandhi Hospital, New Delhi, India
| | - Guangyong Zou
- Alimentiv Inc, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Virginia Solitano
- Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada; Division of Gastroenterology and Gastrointestinal Endoscopy, IRCCS Ospedale San Raffaele, Università Vita-Salute San Raffaele, Milan, Italy
| | - Gaurav Syal
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Han Hee Lee
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California; Division of Gastroenterology, Department of Internal Medicine, Yeouido St. Mary's Hospital College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Christopher Ma
- Alimentiv Inc, London, Ontario, Canada; Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Vipul Jairath
- Alimentiv Inc, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada; Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada.
| | - Siddharth Singh
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California; Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, California.
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Roblin X, Little RD, Mathieu N, Paul S, Nancey S, Barrau M, Sparrow MP. Therapeutic drug monitoring in inflammatory bowel disease: recent developments. Expert Rev Gastroenterol Hepatol 2024; 18:575-586. [PMID: 39382556 DOI: 10.1080/17474124.2024.2409300] [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: 08/05/2024] [Revised: 09/03/2024] [Accepted: 09/23/2024] [Indexed: 10/10/2024]
Abstract
INTRODUCTION Therapeutic Drug Monitoring (TDM) has an important role in the management of inflammatory bowel disease (IBD) patients on infliximab (IFX) or adalimumab and is recommended in IBD patients presenting a loss of response under anti TNF agent. But, TDM was not recommended for others biotherapies. AREAS COVERED Analyzing all publications about TDM and biologics in IBD patients, we reported the major results for each biotherapy. EXPERT OPINION Emerging data suggest that TDM will probably be similarly useful forIFX SC. In contrast, there is no demonstrated clinical benefit to the use of TDM with golimumab. For vedolizumab results for the use of both reactive and proactive TDM are discordant. For ustekinumab, data supports the existence of an exposure response relationship, albeit of a lesser magnitude than with anti-TNF agents. Finally, recent data from small case series suggests that TDM could be valuable in optimizing anti-IL23 agents, particularly risankizumab, but this requires further clarification. Consistent with the new concept of 'proactive' strategy, recent data support the utility of dashboard-driven model informed precision dosing (MIDP) of anti-TNF agents, in particular infliximab. Dashboards are software systems using Bayesian population pharmacokinetic modelling to individualize recommendations for target drug levels.
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Affiliation(s)
- Xavier Roblin
- Gastroenterology, University Hospital of Saint Etienne, Saint Etienne, France
- IBD Private Institute Echirolles, Echirolles, France
| | - Robert D Little
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne, Australia
| | | | - Stephane Paul
- Immunology, University Hospital of Saint Etienne, Saint Etienne, France
| | | | - Mathide Barrau
- Gastroenterology, University Hospital of Saint Etienne, Saint Etienne, France
| | - Miles P Sparrow
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne, Australia
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Chanchlani N, Lin S, Bewshea C, Hamilton B, Thomas A, Smith R, Roberts C, Bishara M, Nice R, Lees CW, Sebastian S, Irving PM, Russell RK, McDonald TJ, Goodhand JR, Ahmad T, Kennedy NA. Mechanisms and management of loss of response to anti-TNF therapy for patients with Crohn's disease: 3-year data from the prospective, multicentre PANTS cohort study. Lancet Gastroenterol Hepatol 2024; 9:521-538. [PMID: 38640937 DOI: 10.1016/s2468-1253(24)00044-x] [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] [Received: 09/26/2023] [Revised: 01/31/2024] [Accepted: 02/09/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND We sought to report the effectiveness of infliximab and adalimumab over the first 3 years of treatment and to define the factors that predict anti-TNF treatment failure and the strategies that prevent or mitigate loss of response. METHODS Personalised Anti-TNF therapy in Crohn's disease (PANTS) is a UK-wide, multicentre, prospective observational cohort study reporting the rates of effectiveness of infliximab and adalimumab in anti-TNF-naive patients with active luminal Crohn's disease aged 6 years and older. At the end of the first year, sites were invited to enrol participants still receiving study drug into the 2-year PANTS-extension study. We estimated rates of remission across the whole cohort at the end of years 1, 2, and 3 of the study using a modified survival technique with permutation testing. Multivariable regression and survival analyses were used to identify factors associated with loss of response in patients who had initially responded to anti-TNF therapy and with immunogenicity. Loss of response was defined in patients who initially responded to anti-TNF therapy at the end of induction and who subsequently developed symptomatic activity that warranted an escalation of steroid, immunomodulatory, or anti-TNF therapy, resectional surgery, or exit from study due to treatment failure. This study was registered with ClinicalTrials.gov, NCT03088449, and is now complete. FINDINGS Between March 19, 2014, and Sept 21, 2017, 389 (41%) of 955 patients treated with infliximab and 209 (32%) of 655 treated with adalimumab in the PANTS study entered the PANTS-extension study (median age 32·5 years [IQR 22·1-46·8], 307 [51%] of 598 were female, and 291 [49%] were male). The estimated proportion of patients in remission at the end of years 1, 2, and 3 were, for infliximab 40·2% (95% CI 36·7-43·7), 34·4% (29·9-39·0), and 34·7% (29·8-39·5), and for adalimumab 35·9% (95% CI 31·2-40·5), 32·9% (26·8-39·2), and 28·9% (21·9-36·3), respectively. Optimal drug concentrations at week 14 to predict remission at any later timepoints were 6·1-10·0 mg/L for infliximab and 10·1-12·0 mg/L for adalimumab. After excluding patients who had primary non-response, the estimated proportions of patients who had loss of response by years 1, 2, and 3 were, for infliximab 34·4% (95% CI 30·4-38·2), 54·5% (49·4-59·0), and 60·0% (54·1-65·2), and for adalimumab 32·1% (26·7-37·1), 47·2% (40·2-53·4), and 68·4% (50·9-79·7), respectively. In multivariable analysis, loss of response at year 2 and 3 for patients treated with infliximab and adalimumab was predicted by low anti-TNF drug concentrations at week 14 (infliximab: hazard ratio [HR] for each ten-fold increase in drug concentration 0·45 [95% CI 0·30-0·67], adalimumab: 0·39 [0·22-0·70]). For patients treated with infliximab, loss of response was also associated with female sex (vs male sex; HR 1·47 [95% CI 1·11-1·95]), obesity (vs not obese 1·62 [1·08-2·42]), baseline white cell count (1·06 [1·02-1·11) per 1 × 109 increase in cells per L), and thiopurine dose quartile. Among patients treated with adalimumab, carriage of the HLA-DQA1*05 risk variant was associated with loss of response (HR 1·95 [95% CI 1·17-3·25]). By the end of year 3, the estimated proportion of patients who developed anti-drug antibodies associated with undetectable drug concentrations was 44·0% (95% CI 38·1-49·4) among patients treated with infliximab and 20·3% (13·8-26·2) among those treated with adalimumab. The development of anti-drug antibodies associated with undetectable drug concentrations was significantly associated with treatment without concomitant immunomodulator use for both groups (HR for immunomodulator use: infliximab 0·40 [95% CI 0·31-0·52], adalimumab 0·42 [95% CI 0·24-0·75]), and with carriage of HLA-DQA1*05 risk variant for infliximab (HR for carriage of risk variant: infliximab 1·46 [1·13-1·88]) but not for adalimumab (HR 1·60 [0·92-2·77]). Concomitant use of an immunomodulator before or on the day of starting infliximab was associated with increased time without the development of anti-drug antibodies associated with undetectable drug concentrations compared with use of infliximab alone (HR 2·87 [95% CI 2·20-3·74]) or introduction of an immunomodulator after anti-TNF initiation (1·70 [1·11-2·59]). In years 2 and 3, 16 (4%) of 389 patients treated with infliximab and 11 (5%) of 209 treated with adalimumab had adverse events leading to treatment withdrawal. Nine (2%) patients treated with infliximab and two (1%) of those treated with adalimumab had serious infections in years 2 and 3. INTERPRETATION Only around a third of patients with active luminal Crohn's disease treated with an anti-TNF drug were in remission at the end of 3 years of treatment. Low drug concentrations at the end of the induction period predict loss of response by year 3 of treatment, suggesting higher drug concentrations during the first year of treatment, particularly during induction, might lead to better long-term outcomes. Anti-drug antibodies associated with undetectable drug concentrations of infliximab, but not adalimumab, can be predicted by carriage of HLA-DQA1*05 and mitigated by concomitant immunomodulator use for both drugs. FUNDING Guts UK, Crohn's and Colitis UK, Cure Crohn's Colitis, AbbVie, Merck Sharp and Dohme, Napp Pharmaceuticals, Pfizer, and Celltrion Healthcare.
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Affiliation(s)
- Neil Chanchlani
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Simeng Lin
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Claire Bewshea
- Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Benjamin Hamilton
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Amanda Thomas
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Rebecca Smith
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Christopher Roberts
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Maria Bishara
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Rachel Nice
- Department of Blood Science, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Charlie W Lees
- Department of Gastroenterology, Edinburgh IBD Unit, Western General Hospital, NHS Lothian, Edinburgh, UK; Institute of Genetic and Cancer, University of Edinburgh, Edinburgh, UK
| | - Shaji Sebastian
- Gastroenterology and Hepatology, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK; Hull York Medical School, University of Hull, Hull, UK
| | - Peter M Irving
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK; School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children & Young People, Edinburgh, UK; Child Life and Health, University of Edinburgh, Royal Hospital for Children & Young People, Edinburgh, UK
| | - Timothy J McDonald
- Department of Blood Science, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - James R Goodhand
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Tariq Ahmad
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Nicholas A Kennedy
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK.
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10
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Chapman TP, Ahmad T, Satsangi J. Use of immunomodulators in combination with infliximab in Crohn's disease: time for a reappraisal? Lancet Gastroenterol Hepatol 2024; 9:402-405. [PMID: 38402894 DOI: 10.1016/s2468-1253(23)00406-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 11/21/2023] [Indexed: 02/27/2024]
Affiliation(s)
- Thomas P Chapman
- Department of Gastroenterology, St Richard's and Worthing Hospitals, University Hospitals Sussex NHS Foundation Trust, West Sussex, UK; Translational Gastroenterology Unit, Nuffield Department of Experimental Medicine, University of Oxford, Oxford, UK.
| | - Tariq Ahmad
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Jack Satsangi
- Translational Gastroenterology Unit, Nuffield Department of Experimental Medicine, University of Oxford, Oxford, UK
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11
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Sun M, Ju J, Xu H, Luo M, Li Z, Wang Y. Antibiotics influence the risk of anti-drug antibody formation during anti-TNF therapy in Chinese inflammatory bowel disease patients. Front Pharmacol 2024; 15:1360835. [PMID: 38655181 PMCID: PMC11035825 DOI: 10.3389/fphar.2024.1360835] [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: 12/24/2023] [Accepted: 03/20/2024] [Indexed: 04/26/2024] Open
Abstract
Aims: The formation of anti-drug antibodies (ADAs) during anti-tumor necrosis factor (anti-TNF) therapy is reported to lead to reducing serum drug levels, which may bring about a loss of response to treatment. Previous research has suggested an association between specific antibiotic classes and ADA formation during anti-TNF therapy. However, there are few studies specifically examining this association in Chinese inflammatory bowel disease (IBD) patients. Therefore, our study aimed to evaluate the possible effect of antibiotic use on ADA formation to anti-TNF therapy in Chinese patients with IBD. Methods: A total of 166 patients with IBD, including 149 with Crohn's disease (CD) and 17 with ulcerative colitis (UC), were included in this retrospective analysis. These patients were initially treated with anti-TNF therapy (infliximab or adalimumab) after January 2018 and reviewed with available ADA levels before October 2023. After univariable analysis of all the variables, a multivariate Cox proportional hazards model was used to assess the association between antibiotic use and ADA development. Results: Among 166 IBD patients treated with infliximab (108/166, 65.1%) or adalimumab (58/166, 34.9%), 31 patients (18.7%) were measured as positive ADA levels. Cox proportional hazard model demonstrated an increased risk of ADA formation in IBD patients who used β-lactam-β-lactamase inhibitor combinations (BL-BLIs) (HR = 5.143, 95%CI 1.136-23.270, p = 0.033), or nitroimidazoles (HR = 4.635, 95%CI 1.641-13.089, p = 0.004) during 12 months before the ADA test. On the contrary, a reduced risk was noted in patients treated with fluoroquinolones (HR = 0.258, 95% CI 0.072-0.924, p = 0.037). Moreover, the median serum infliximab or adalimumab concentration in patients with positive ADA levels was significantly lower than that in patients with negative ADA levels (infliximab: 0.30 vs. 1.85 μg/mL, p < 0.0001; adalimumab: 0.45 vs. 7.55 μg/mL, p = 0.0121). Conclusion: ADA development is associated with various antibiotic classes. BL-BLIs and nitroimidazoles might increase the risk of ADA formation during anti-TNF therapy in Chinese IBD patients, while the treatment with fluoroquinolones could probably reduce such risk. There were certain limitations in the retrospective analysis of the study, therefore, the results are just for reference, and other studies are needed to further confirm our findings.
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Affiliation(s)
| | | | | | | | | | - Yufang Wang
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
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12
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de Beaumais TA, Lorrain S, Mamhoudi N, Simonin M, Martinez Vinson C, Medard Y, Petit A, Jacqz-Aigrain E. Key factors associated with 6-thioguanine and 6-methylmercaptopurine nucleotide concentrations in children treated by thiopurine for acute leukaemia and inflammatory bowel disease. Br J Clin Pharmacol 2024; 90:209-219. [PMID: 37621013 DOI: 10.1111/bcp.15894] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 07/10/2023] [Accepted: 08/05/2023] [Indexed: 08/26/2023] Open
Abstract
AIMS Azathioprine (AZA) and 6-mercaptopurine are prescribed in acute lymphoblastic leukaemia (ALL) and inflammatory bowel diseases (IBD). Metabolism to active 6-thioguanine (6TGN) and 6-methylmercaptopurine nucleotides (6MMPN) is variable but therapeutic drug monitoring (TDM) remains debatable. This study reports on factors impacting on red blood cell (RBC) metabolites concentrations in children to facilitate TDM interpretation. METHODS The first paediatric TDM samples received during year 2021 were analysed, whatever indication and thiopurine drug. Target concentration ranges were 200-500, <6000 pmol/8 × 108 RBC for 6TGN and 6MMPN. RESULTS Children (n = 492) had IBD (64.8%), ALL (22.6%) or another autoimmune disease (12.6%): mean ages at TDM were 7.5 in ALL and 13.7 years in IBD (P < .0001). ALL received 6-mercaptopurine (mean dose 1.7 mg/kg/d with methotrexate), IBD received AZA (1.9 mg/kg/d with anti-inflammatory drugs and/or monoclonal antibodies). Median 6TGN and 6MMPN concentrations were 213.7 [interquartile range: 142.5; 309.6] and 1144.6 [419.4; 3574.3] pmol/8 × 108 RBC, 38.8% of patients were in the recommended therapeutic range for both compounds. Aminotransferases and blood tests were abnormal in 57/260 patients: 8.1% patients had high alanine aminotransaminase, 3.4% of patients had abnormal blood count. Factors associated with increased 6TGN were age at TDM and thiopurine methyltransferase genotype in ALL and AZA dose in IBD. The impact of associated treatment in IBD patients was also significant. CONCLUSION TDM allowed identification of children who do not reach target levels or remain over treated. Including TDM in follow-up may help physicians to adjust dosage with the aim of reducing adverse effects and improve treatment outcome.
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Affiliation(s)
- Tiphaine Adam de Beaumais
- Department of Biological Pharmacology and Pharmacogenetics, Hôpital Saint-Louis, Assistance Publique - Hôpitaux de Paris, France
| | - Simon Lorrain
- Centre d'Etudes Périnatales de l'Océan Indien (UR 7388), Université de La Réunion, Saint-Pierre, France
| | - Naura Mamhoudi
- Department of Biological Pharmacology and Pharmacogenetics, Hôpital Saint-Louis, Assistance Publique - Hôpitaux de Paris, France
- University Paris Cité, Paris, France
| | - Mathieu Simonin
- Department of Pediatric Hematology and Oncology, Hôpital Armand Trousseau, Assistance Publique - Hôpitaux de Paris, France
- Sorbonne University, Paris, France
| | - Christine Martinez Vinson
- University Paris Cité, Paris, France
- Department of Pediatric Gastroenterology and Nutrition, Hôpital Robert Debré, Assistance Publique - Hôpitaux de Paris, France
| | - Yves Medard
- Department of Biological Pharmacology and Pharmacogenetics, Hôpital Saint-Louis, Assistance Publique - Hôpitaux de Paris, France
| | - Arnaud Petit
- Department of Pediatric Hematology and Oncology, Hôpital Armand Trousseau, Assistance Publique - Hôpitaux de Paris, France
- Sorbonne University, Paris, France
| | - Evelyne Jacqz-Aigrain
- Department of Biological Pharmacology and Pharmacogenetics, Hôpital Saint-Louis, Assistance Publique - Hôpitaux de Paris, France
- University Paris Cité, Paris, France
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13
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Katibian DJ, Solitano V, Polk DB, Nguyen T, Ma C, Syal G, Kobayashi T, Hibi T, Buhl S, Ainsworth MA, Jairath V, Singh S. Withdrawal of Immunomodulators or TNF Antagonists in Patients With Inflammatory Bowel Diseases in Remission on Combination Therapy: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2024; 22:22-33.e6. [PMID: 37716619 DOI: 10.1016/j.cgh.2023.08.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/25/2023] [Accepted: 08/19/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND & AIMS Withdrawal of immunomodulators (IMMs) or tumor necrosis factor (TNF) antagonists in patients with inflammatory bowel diseases (IBDs) in remission on combination therapy is attractive. We evaluated the efficacy and safety of (1) IMM, or (2) TNF antagonist withdrawal in patients with IBD in sustained remission on combination therapy. METHODS Through a systematic review till March 31, 2023, we identified randomized controlled trials (RCTs) that compared the efficacy and safety of IMM or TNF antagonist withdrawal vs continued combination therapy, in patients with IBD in sustained corticosteroid-free clinical remission for >6 months on combination therapy. Primary outcome was risk of relapse and serious adverse events at 12 months. We conducted meta-analysis to calculate relative risk (RR) and 95% confidence interval (CI) and used Grading of Recommendations Assessment, Development and Evaluation (GRADE) to appraise certainty of evidence. RESULTS We identified 8 RCTs with 733 patients (77% with Crohn's disease, 91% on infliximab-based combination therapy). On meta-analysis of 5 RCTs, there was no difference in the risk of relapse between patients with IMM withdrawal (continued TNF antagonist monotherapy) vs continued combination therapy (16.8% vs 14.9%; RR, 1.15; 95% CI, 0.75-1.76) without heterogeneity (low certainty of evidence). TNF antagonist withdrawal (continued IMM monotherapy) was associated with 2.4-times higher risk of relapse compared with continuing combination therapy (31.5% vs 11.2%; RR, 2.35; 95% CI, 1.38-4.01), with minimal heterogeneity (low certainty of evidence). There was no difference in the risk of serious adverse events with IMM or TNF antagonist withdrawal vs continued combination therapy. CONCLUSIONS In patients with IBD in sustained corticosteroid-free clinical remission for >6 months on combination therapy, de-escalation with TNF antagonist withdrawal, but not IMM withdrawal, was associated with an increased risk of relapse.
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Affiliation(s)
- David J Katibian
- Division of Gastroenterology, Hepatology and Nutrition, Rady Children's Hospital, San Diego, California; Department of Pediatrics, University of California, San Diego, La Jolla, California
| | - Virginia Solitano
- Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada; Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - D Brent Polk
- Division of Gastroenterology, Hepatology and Nutrition, Rady Children's Hospital, San Diego, California; Department of Pediatrics, University of California, San Diego, La Jolla, California
| | - Tran Nguyen
- Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada
| | - Christopher Ma
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Alimentiv Inc, London, Ontario, Canada
| | - Gaurav Syal
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Taku Kobayashi
- Center for Advanced IBD Research and Treatment; Kitasato University, Tokyo, Japan
| | - Toshifumi Hibi
- Center for Advanced IBD Research and Treatment; Kitasato University, Tokyo, Japan
| | - Sine Buhl
- Department of Gastroenterology, Copenhagen University Hospital-Herlev and Gentofte, Herlev, Denmark
| | - Mark Andrew Ainsworth
- Department of Medical Gastroenterology S, Odense University Hospital, Odense, Denmark
| | - Vipul Jairath
- Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada; Alimentiv Inc, London, Ontario, Canada; Department of Epidemiology & Biostatistics, Western University, London, Ontario, Canada
| | - Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California; Division of Biomedical Informatics, University of California San Diego, La Jolla, California.
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Patel S, Yarur AJ. A Review of Therapeutic Drug Monitoring in Patients with Inflammatory Bowel Disease Receiving Combination Therapy. J Clin Med 2023; 12:6577. [PMID: 37892715 PMCID: PMC10607463 DOI: 10.3390/jcm12206577] [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: 07/07/2023] [Revised: 09/27/2023] [Accepted: 10/14/2023] [Indexed: 10/29/2023] Open
Abstract
Background: Inflammatory Bowel Disease (IBD) impacts millions worldwide, presenting a major challenge to healthcare providers and patients. The advent of biologic therapies has enhanced the prognosis, but many patients exhibit primary or secondary non-response, underscoring the need for rigorous monitoring and therapy optimization to improve outcomes. Objective: This narrative review seeks to understand the role of therapeutic drug monitoring (TDM) in optimizing treatment for IBD patients, especially for those on combination therapies of biologics and immunomodulators. Methods: A comprehensive synthesis of the current literature was undertaken, focusing on the application, benefits, limitations, and future directions of TDM in patients receiving a combination of biologic therapies and immunomodulators. Results: While biological therapies have improved outcomes, rigorous monitoring and therapy optimization are needed. TDM has emerged as a pivotal strategy, enhancing outcomes cost-effectively while reducing adverse events. While most data pertain to monotherapies, TDM's applicability also extends to combination therapy. Conclusion: TDM plays a crucial role in the treatment optimization of IBD patients on combination therapies. Further research is needed to fully understand its potential and limitations in the broader context of IBD management.
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Affiliation(s)
| | - Andres J. Yarur
- Cedars-Sinai Medical Center, 8730 Alden Dr., Los Angeles, CA 90048, USA
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15
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Bouhuys M, Mian P, van Rheenen PF. Ustekinumab trough levels in children with Crohn's disease refractory to anti-tumor necrosis factor agents: a prospective case series of off-label use. Front Pharmacol 2023; 14:1180750. [PMID: 37818191 PMCID: PMC10561290 DOI: 10.3389/fphar.2023.1180750] [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: 03/06/2023] [Accepted: 09/11/2023] [Indexed: 10/12/2023] Open
Abstract
Background: Ustekinumab is used off-label in pediatric Crohn's disease refractory to anti-tumor necrosis factor. Data on optimal dosing, target trough levels, and potential benefit of therapeutic drug monitoring in children treated with ustekinumab are limited. Materials and Methods: We describe a series of six adolescents who consented to be treated with ustekinumab. We measured their trough levels, C-reactive protein, and fecal calprotectin before every administration. Results: Standard adult dosing was effective to achieve biochemical remission (fecal calprotectin < 250 mg/kg) in one patient and clinical remission (resolution of symptoms) in another. The other four patients failed to respond on standard dosing and underwent intravenous re-induction and interval shortening to increase ustekinumab trough levels. This resulted in biochemical remission in one patient and clinical remission in another, suggesting an exposure-response relationship. The remaining two patients had no therapeutic benefit, and ustekinumab was discontinued. Conclusion: In this report, we show that ustekinumab can induce remission in pediatric patients with anti-tumor necrosis factor refractory Crohn's disease. It is worth escalating the dose before abandoning the drug as ineffective. Prospective studies in children are needed to determine long-term efficacy of ustekinumab, usefulness of therapeutic drug monitoring strategies, and, if applicable, optimal target trough levels.
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Affiliation(s)
- Marleen Bouhuys
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Beatrix Children’s Hospital, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Paola Mian
- Department of Clinical Pharmacy and Pharmacology, University Medical Centre Groningen, Groningen, Netherlands
| | - Patrick F. van Rheenen
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Beatrix Children’s Hospital, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
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