Novel biologics in inflammatory bowel disease

Biosimilar medicines uptake: The role of the clinical pharmacist

The introduction of biological medicines has revolutionized the management of chronic diseases. Due to the high cost of biological medicine coupled with the fact that patents of many of these medicines are on the verge of expiration, manufacturers are exploring the production of biosimilars. The introduction of biosimilars has the capacity to increase competition among manufacturers, reduce prices, and improve patient access to these medicines. Therefore, a biosimilar is a new wave in therapy and treatment for the next few years. Despite the growing number of biosimilars approved for patient care, physicians' comfort in prescribing reference products against biosimilars and patient reluctance to switch from a reference product to a biosimilar are the major barriers for biosimilar increasing use. This paper aims to highlight the role of the clinical pharmacist (CP) in the utilization of biosimilars and the need for a pharmacy specialty regarding biosimilars. Of all the healthcare providers, CP has the most holistic view of the biosimilar products' clinical profile, and logistical and supply chain considerations. Thus, CPs are uniquely positioned to better educate all biosimilar medicine key stakeholders in an effort to increase access and rational use.

Certolizumab pegol for the treatment of Crohn's disease

Certolizumab pegol is a polyethylene glycolated FAb' fragment of a humanized anti-TNF-alpha monoclonal antibody. This pegylated molecule binds with circulating TNF-alpha and forms an inactive complex that is then eliminated from the body. The drug has been shown to be better than placebo in the treatment of Crohn's disease and maintaining a clinical response in adult patients with moderate-to-severe active disease who have had an inadequate response to conventional therapy, and the treatment of adults with moderately to severely active rheumatoid arthritis. Comparative trials with an active control group are lacking. The most common adverse reactions include abdominal pain, diarrhea, injection site reactions and infection. All necessary live and attenuated vaccines should be given prior to the initiation of certolizumab pegol therapy, patients should be evaluated for TB risk factors and tested for latent TB prior to initiating therapy, and the initiation of therapy should be avoided if the patient has an active infection. Concomitant use with anakinra is not recommended because of the increased risk of serious infections and neutropenia. Therapy should be discontinued if the patient develops a serious infection during therapy.

Disseminated coccidioidomycosis in a patient managed with adalimumab for Crohn's disease

BACKGROUND

A 50-year-old man presented with a 2-3 month history of left lower quadrant abdominal pain, right periorbital headache, blurry vision, tinnitus, polydipsia, right elbow pain, and a 32 kg weight loss over the past year. He had a 34-year history of complicated Crohn's disease that was notable for surgical stricture repair and partial colectomy for bowel perforation. The patient was receiving mesalazine and 6-mercaptopurine and, 2 months before admission, had stopped a 4-month therapy course with the biologic agent adalimumab for treatment of Crohn's disease.

INVESTIGATIONS

Physical examination, brain and elbow MRI scans, chest CT scan, routine blood analyses, assessment of coccidioidomycosis antibody levels, immunodiffusion and complement fixation studies in serum and cerebrospinal fluid, full-body technetium-99m nuclear bone scan, hematoxylin and eosin staining of resected tissue specimens.

DIAGNOSIS

Disseminated coccidioidomycosis with meningeal, bone, soft tissue and pulmonary involvement.

MANAGEMENT

The patient underwent treatment with amphotericin B liposomal complex and oral fluconazole and right elbow surgical debridement and irrigation. All immunosuppressive therapy was stopped.

Fungal infections complicating tumor necrosis factor alpha blockade therapy

Tumor necrosis factor a (TNF-alpha) blockade has emerged as a useful therapy for collagen vascular diseases or graft-vs-host disease. Fungal infections complicating such therapy have been reported sporadically. MEDLINE and PubMed databases (from January 1, 1966, to June 1, 2007) were searched for reports of invasive fungal infections (IFIs) associated with the 3 available anti-TNF- alpha agents, ie, infliximab, etanercept, and adalimumab. Of the 281 cases of IFI associated with TNF-alpha inhibition, 226 (80%) were associated with infliximab, 44 (16%) with etanercept, and 11 (4%) with adalimumab. Fungal infections associated with infliximab occurred a median of 55 days (interquartile range [IQR], 15-140 days) after initiation of therapy and 3 infusions of the medication (IQR, 2-5), whereas those associated with etanercept occurred a median of 144 days (IQR, 46-240 days) after initiation of therapy. The median age of patients was 58 years (IQR, 44-68 years), and 62% were male. Use of at least 1 other immunosuppressant medication, typically a systemic corticosteroid, was reported during the course of the fungal infection in 102 (98%) of the 104 patients for whom data were available. The most prevalent IFIs were histoplasmosis (n=84 [30%]), candidiasis (n=64 [23%]), and aspergillosis (n equals 64 [23%]). Pneumonia was the most common pattern of infection. Of the 90 (32%) of 281 cases for which outcome information was available, 29 fatalities (32%) were recorded. Tumor necrosis factor a blockade is associated with IFI across a range of host groups. A high index of suspicion in patients treated with TNF-alpha antagonists is recommended because the course of such infections can be serious or fulminant, and rapid access to health care should be provided. Surveillance of IFIs complicating TNF-alpha blockade and other biologic therapies is warranted through well-organized prospective patient registries.

Treatment of immune-mediated extraintestinal manifestations of inflammatory bowel disease with infliximab

The introduction of infliximab into clinical practice is one of the most significant advances in the care of patients who have IBD. Infliximab has become an important part of the medical armamentarium to treat extraintestinal manifestations that often are refractory to other medications and are a significant cause of morbidity in these patients. Two other TNF inhibitors recently have demonstrated efficacy in CD: certolizumab pegol and adalimumab. The Food and Drug Administration has approved adalimumab for use in RA. One predicts that these agents also may have activity in the extraintestinal manifestation for IBD. To determine whether future biologics are effective in the EIM of IBD, one may need to look no further than the vast clinical trial experience in primary chronic inflammatory diseases of the joints and skin: RA and psoriasis. For example, the Food and DRug Administration recently has approved an anti-B-cell therapy, rituximab, and a T-cell costimulation modulator, abatacept, for use in RA. It certainly will be of interest to determine whether these biologic agents demonstrate efficacy in the intestinal and EIM of IBD.

Infliximab: Use in Inflammatory Bowel Disease

Crohn's disease (CD) and ulcerative colitis (UC) are chronic and often debilitating inflammatory bowel diseases (IBD) without medical cures. Despite the existence of multiple therapies, the medical treatment of these diseases often has proven insufficient and surgery is frequently required. However, as our understanding of the pathogenesis of these disorders and other immune-mediated inflammatory diseases (eg, rheumatoid arthritis and psoriasis) has grown, new and more specific biologic therapies have been developed that are proving more effective than traditional agents. Infliximab is a genetically engineered monoclonal antibody that targets the proinflammatory cytokine tumor necrosis factor-alpha (TNF-alpha) and represents the first effective biologic therapy for IBD and has largely revolutionized treatment. Infliximab initially was developed to be used in patients with moderate to severe luminal or fistulizing CD who are refractory to standard medical therapy. More and more practitioners now are using infliximab as first-line therapy because of its superior efficacy. Infliximab rapidly induces remission in CD, but when given chronically, it can provide long-term maintenance of remission. In addition, there are some data to support its use as a steroid-sparing agent and treatment for various extraintestinal manifestations of IBD and, although used predominantly to treat CD, recent data suggest that infliximab also may have a role in the management of UC. Overall, infliximab represents a clinically useful, cost-effective therapy that works well, even though careful patient monitoring is required to avoid rare but significant toxicities. The hope is that infliximab, together with other biologic agents that currently are in development, will allow us to modify the course of IBD, avoid complications such as strictures and abscesses, and reduce the need for surgery.

A STAT need for human immunologic studies to understand inflammatory bowel disease

In this issue of The American Journal of Gastroenterology, Mudter et al. present a study elucidating a potential role for STAT proteins in the pathogenesis of the human inflammatory bowel diseases (IBDs). The importance of this study lies in the methodology, as molecular biology was applied to humans to describe expression and activation of STATs in intestinal mucosal cells from IBD patients. The speculative roles for the family members/STAT1 and STAT3 suggest a divergence between human IBD and immunologic hypotheses derived from murine models. This work provides an example of why technology and experiments to understand human immunology are ultimately our best strategy to develop therapies and biomarkers for IBD.