An update on anti-TNF agents in ulcerative colitis

Two-Photon Probe for TNF-α. Assessment of the Transmembrane TNF-α Level in Human Colon Tissue by Two-Photon Microscopy

We developed Pyr1-infliximab: a two-photon probe for TNF-α. Pyr1-infliximab showed absorption maxima at 280 and 438 nm and an emission maximum at 610 nm in an aqueous buffer and effective two-photon action cross-section values of (520-2830) × 10^-50 cm⁴s/photon in RAW 264.7 cells. After this probe was labeled, it was possible to detect Pyr1-infliximab-transmembrane TNF-α complexes in a live cell and to determine the relative proportion of these complexes in human colon tissues. This proportion among healthy, possibly inflamed, and inflamed tissues of patients with ulcerative colitis was found to be 1.0/4.5/10. This probe may find useful applications for selective detection of transmembrane TNF-α in a live cell or tissue, for quantification of inflammation in human colon tissue or of antidrug antibodies in patients who stop responding to anti-TNF therapy, and for monitoring of the response to this therapy.

Golimumab: early experience and medium-term outcomes from two UK tertiary IBD centres

OBJECTIVE

To gain an understanding of the effectiveness of golimumab in a 'real-world' setting.

DESIGN

Retrospective cohort study using prospectively maintained clinical records.

SETTING

Two UK tertiary IBD centres.

PATIENTS

Patients with ulcerative colitis (UC) were given golimumab at Guy's & St Thomas and King's College Hospitals between September 2014 and December 2016.

INTERVENTION

Golimumab, a subcutaneously administered antitumour necrosis factor agent.

MAIN OUTCOME MEASURES

Clinical disease activity was assessed at baseline and at the first clinical review following induction therapy using the Simple Clinical Colitis Activity Index (SCCAI). Response was defined as an SCCAI reduction of 3 points or more. Remission was defined as an SCCAI of less than 3.

RESULTS

Fifty-seven patients with UC completed golimumab induction therapy. Paired preinduction and postinduction SCCAI values were available for 31 patients and fell significantly from 7 (2-19) to 3 (0-11) (p<0.001). To these 31, an additional 13 patients who did not have paired SCCAI data but stopped treatment due to documented 'non-response' in the opinion of their supervising clinician, were added. Among this combined cohort, 23/44 (52%) had a clinical response, 15/44 (34%) achieved remission and 13/44 (30%) achieved corticosteroid-free remission.Faecal calprotectin and CRP fell (FC: pre-induction: 1096 (15-4800) μg/g, post-induction: 114 (11-4800) μg/g, p = 0.011; n = 20; CRP: pre-induction: 4 (1-59) mg/L, post-induction: 2 (1-34) mg/L, p = 0.01 for n = 43). Post-induction endoscopy was carried out in 23 patients and a mucosal healing (Mayo 0 or 1) rate of 35% was observed.

CONCLUSIONS

Our experience mirrors previously reported real-world cohorts and demonstrates similar outcomes to those observed in randomised controlled trials. These data demonstrate a meaningful reduction in clinical, biochemical and endoscopic disease activity as well as a steroid-sparing effect in patients with previously refractory disease.

Caudal type homeobox 2 expression induced by leukocytapheresis might be associated with mucosal healing in ulcerative colitis

BACKGROUND AND AIM

Ulcerative colitis (UC) is a chronic inflammatory disease of the colon with an intractable, recurrent course. Although the goal of UC therapy has recently been to target mucosal healing, the molecular mechanism of mucosal healing remains unknown. In this study, we aimed to elucidate the molecular dynamics related to the proliferation and differentiation of intestinal epithelial cells during cytapheresis therapy in a short duration.

METHODS

Endoscopy was performed in 26 patients with UC in multicentre hospitals, and biopsy specimens were collected from the rectum before and within two weeks after leukocytapheresis (LCAP). The expression of representative proteins in intestinal epithelial cells and pathological findings was compared before and after LCAP.

RESULTS

The expression of caudal type homeobox 2 (CDX2) and a hes family bHLH transcription factor 1(HES1) markedly increased after LCAP. Patients with endoscopic improvement after LCAP showed the expression of CDX2 before LCAP. Moreover, the number of goblet cells significantly increased after LCAP. Patients without endoscopic improvement after LCAP did not show the expression of CDX2 before LCAP. However, the expression of CDX2 markedly increased after LCAP.

CONCLUSION

This study suggests that cytapheresis might induce CDX2 expression without affecting the cell proliferation, thus resulting in mucosal healing with goblet cell restoration.

Vedolizumab for the treatment of ulcerative colitis

A substantial proportion of patients with ulcerative colitis (UC) have failed conventional therapies such as steroids, immunosuppressants or TNF-antibodies, or have experienced side effects. This article reviews the pharmacological properties of vedolizumab (VDZ), its efficacy and side effects in UC. By its relatively specific gut-selective mode of action, VDZ's safety profile appears more favorable than that of anti-TNF therapies. VDZ is more effective than placebo for the induction and maintenance of remission in moderate-to-severe UC in both naïve patients and patients who have failed anti-TNF treatment. However, in some patients, VDZ has a slower onset of action. But, to place VDZ as a first-line therapy, it must go head-to-head with azathioprine and anti-TNF antibodies in future studies.

Gastroenterologists' Perceptions Regarding Ulcerative Colitis and Its Management: Results from a Large-Scale Survey

Introduction

Misperceptions about ulcerative colitis (UC) may influence management strategies and limit opportunities for improving patient outcomes. This study assessed physicians’ perceptions of UC, concepts of disease severity and remission, and treatment goals.

Methods

Gastroenterologists who typically treated ≥10 adults with UC per month were recruited for a large-scale, web-based survey. Participants were asked about their perceptions of UC (often vs. Crohn’s disease [CD]), treatment goals, and medication use. Response data were evaluated via descriptive statistics and univariate and multivariable analyses.

Results

Gastroenterologists (N = 500) with a mean of 16.5 years (standard deviation, 8.7 years) in practice participated. In comparison to CD, survey respondents perceived UC as being easier to diagnose, having better treatment outcomes, and being associated with later prescribing of biologics. Treatment goals commonly considered to have the greatest importance included quality of life improvement (31.2% of respondents), maintenance of clinical remission (17.4%), and mucosal healing (17.4%). When respondents evaluated the performance of medication classes in achieving these goals, biologics were rated significantly higher than all other classes (P < 0.05). However, the most common drivers for the initiation of biologic therapy were the development of steroid refractoriness (66.8%) and steroid dependency (65.8%). Medication class use by UC severity was generally consistent with the traditional step-up approach to UC therapy, with biologics being used most commonly for severe UC.

Conclusion

These results suggest a possible disparity between treatment goals and therapeutic management in UC. An increased awareness of general UC perceptions is an important step toward a better overall understanding of the disease and, ultimately, toward improved management aligned with treatment goals.

Funding

This study was sponsored by the American Gastroenterological Association (AGA), and the design and conduct of the study as well as article processing charges and the open access fee for this publication were funded by Takeda Pharmaceuticals International, Inc. (TPI).

Electronic supplementary material

The online version of this article (doi:10.1007/s12325-016-0393-7) contains supplementary material, which is available to authorized users.

Effects of AVX-470, an Oral, Locally Acting Anti-Tumour Necrosis Factor Antibody, on Tissue Biomarkers in Patients with Active Ulcerative Colitis

BACKGROUND AND AIMS

AVX-470 is an orally administered, bovine-derived, anti-tumour necrosis factor (TNF) antibody with local activity in the gastrointestinal tract. In the first-in-human clinical trial of AVX-470 in active ulcerative colitis, we evaluated inflammatory biomarkers in colon tissue as measures of disease activity and early response to treatment.

METHODS

Thirty-six patients received active drug (AVX-470 at 0.2, 1.6 or 3.5g/day) or placebo over 4 weeks. Colon biopsy samples were collected from 5 regions of colon at baseline and week 4. Tissue inflammatory biomarkers were evaluated by immunohistochemistry and quantitative reverse transcription-polymerase chain reaction (qRT-PCR), epithelial cell apoptosis by terminal deoxynucleotidyl transferase dUTP nick end labelling (TUNEL) and bovine immunoglobulin by immunohistochemistry and mass spectrometry. Endoscopic activity (Ulcerative Colitis Endoscopic Index of Severity [UCEIS]) at colonoscopy was assessed in each colonic region by a central reader.

RESULTS

Bovine immunoglobulin was observed in mucosal tissue before and after dosing in lamina propria and submucosal layers of biopsy tissue. Baseline levels of TNF, myeloperoxidase (MPO), CD68 and interleukin (IL)-1β and, to a lesser extent, IL-6 mRNA were 2- to 3-fold higher in distal vs proximal colon tissue, corresponding to the 2- to 3-fold differences in baseline severities of endoscopic scores. Reductions of >10-fold in TNF and, to lesser extents, in MPO and epithelial cell apoptosis were observed in proximal and distal colon biopsies after 4 weeks of AVX-470 3.5g/day treatment. Reductions in TNF scores were correlated with changes in MPO and CD3 immunohistochemistry scores.

CONCLUSIONS

These results are consistent with anti-TNF activity of orally administered AVX-470 in colon mucosal tissue in ulcerative colitis patients and demonstrate the utility of tissue biomarkers in assessing disease and treatment response in early clinical studies.

CLINICAL TRIAL REGISTRATION NUMBER

This trial was registered with Clinicaltrials.gov as study NCT01759056 and with EudraCT as study 2012-004859-27.

How Will Evolving Future Therapies and Strategies Change How We Position the Use of Biologics in Moderate to Severely Active Inflammatory Bowel Disease

Several biological agents have been added to our armamentarium of treatment options for moderate to severely active inflammatory bowel diseases, and this number is expected to only increase in the near future. With our growing understanding of disease mechanisms and pharmacokinetics, we are now able to target several mechanisms of action to achieve key endpoints (steroid-free remission and mucosal healing) associated with improved long-term disease-related outcomes. In this context, concerns arise regarding the optimal positioning of currently available biologics and key biologics in development. In this review, we will discuss the currently available evidence for comparative effectiveness of biological agents approved for the use in moderate to severely active inflammatory bowel diseases, with a focus on practical considerations to be made when using these agents in practice. We will further review novel biological agents and small molecule inhibitors in development and discuss future opportunities through which providers may personalize treatment decisions to achieve optimal treatment outcomes.

Where are we heading to in pharmacological IBD therapy?

After a relatively long time of failed developments and negative clinical trials in pharmacological inflammatory bowel disease (IBD) therapy we now phase a time of a great number of successful studies and new therapy principles that will most likely make it into clinical practice. This will change the landscape of IBD therapy in future markedly. Many new therapeutic principles have been developed and old ones that seemed to have failed such as anti-sense technology suddenly now provide promising results. Some initially promising therapies will need further development or have failed such as Trichuris suis ova therapy (but not helminth therapy in general), CCR9 targeted therapies or recombinant IL-10. In contrast anti-leukocate trafficking therapies appear to be quite promising. Vedolizumab is the first in class anti-integrin antibody that was approved for the therapy of CD and UC recently. Other anti-integrin antibodies and small molecule adhesion inhibitors will most likely be approved in the next years for IBD therapy. Tofacitinib, a small molecule JAK inhibitor, is a promising candidate for the treatment of UC. Phosphatidylcholine may be a future option for patients with 5-ASA refractory UC or 5-ASA intolerance. The preliminary data for Mongersen, a Smad7 antisense oligonucleotide, are promising despite some concerns about long term effect of TGFβ induction. Anti IL6 strategies will hopefully be further evaluated keeping in mind the caveat of a lack of CRP induction in anti-IL6 treated patients. Stem cell transplantation will become an option for patients that have experienced failure of established medications. Fecal microbiota transplantation and also perhaps combined probiotic therapy is a field that will be evaluated in more detail in the near future especially for UC patients. Based on these new developments treatment algorithms need to be updated. This review will reflect these current developments and give a perspective for future IBD therapy.

Atonal homolog 1 protein stabilized by tumor necrosis factor α induces high malignant potential in colon cancer cell line

Patients with inflammatory bowel disease (IBD) have an increased risk of developing colitis-associated colorectal cancer (CAC). CAC cells often develop chemoresistance, resulting in a poorer prognosis than that of sporadic colorectal cancer (CRC). The mechanism by which CAC enhances malignant potential remains unknown. We have previously reported that the proteasomal degradation of the transcription factor Atonal homolog 1 (Atoh1) protein results in the non-mucinous form of CRC. It also remains unknown whether Atoh1 protein is expressed in CAC. Therefore, in the present study, we investigated whether Atoh1 protein stabilizes in CAC. Consequently, the treatment with TNF-α stabilized Atoh1 protein through the inactivation of GSK-3β via Akt, resulting in the mucinous form of CRC cell lines. Atoh1 protein also enriched cancer stem cells with upregulated Lgr5 expression and cells in G0/G1 cell cycle phase, resulting in both the chemoresistance to 5-fluorouracil and oxaliplatin and the promotion of cell migration. Immunofluorescence of the human mucinous CAC specimens showed the accumulation of NF-κB p65 at nuclei with the expression of Atoh1 in mucinous cancer. In conclusion, the inflammation associated with carcinogenesis may preserve the differentiation system of intestinal epithelial cell (IEC), resulting in the acquisition of both the mucinous phenotype and high malignant potential associated with the enrichment of cancer stem cell.

Infliximab is superior to other biological agents for treatment of active ulcerative colitis: A meta-analysis

AIM: To compare the efficacy and safety of biological agents for the treatment of active ulcerative colitis (UC).

METHODS: PubMed, MEDLINE, EMBASE and the Cochrane library were searched to screen relevant articles from January 1996 to August 2014. The mixed treatment comparison meta-analysis within a Bayesian framework was performed using WinBUGS14 software. The proportions of patients reaching clinical response, clinical remission and mucosal healing in induction and maintenance phases were analyzed as efficacy indicators. Serious adverse events in maintenance phase were analyzed as safety indicators.

RESULTS: The meta-analysis results showed that biological agents achieved better clinical response, clinical remission and mucosal healing than placebo. Indirect comparison indicated that in induction phase, infliximab was more effective than adalimumab in inducing clinical response (OR = 0.41, 95%CI: 0.29-0.57), clinical remission (OR = 0.33, 95%CI: 0.19-0.56) and mucosal healing (OR = 0.33, 95%CI: 0.19-0.56), and golimumab in inducing clinical response (OR = 0.66, 95%CI: 0.39-2.33) and mucosal healing (OR = 2.15, 95%CI: 1.18-4.22). No significant difference was found between placebo and biological agents regarding their safety.

CONCLUSION: All biological agents were superior to placebo for UC treatment in both induction and maintenance phases with a similar safety profile, and infliximab had a better clinical effect than the other biological agents.

Effect of γ-aminobutyric acid on isolated colonic smooth muscle from rats with experimental ulcerative colitis

AIM: To assess the effect of γ-aminobutyric acid (GABA) on isolated colonic smooth muscle from rats with experimental ulcerative colitis (UC).

METHODS: Seventeen Wistar rats were randomly divided into either a normal group (six rats) or a model group (eleven rats). The normal group was given distilled water, while the model group was given distilled water containing 3% dextran sulfate 5000. The body mass of the rats and the character of the stool were observed every day, and the disease active index (DIA) was scored. Nine days later, all the rats were killed to observe the changes of the gross morphology and the pathologic changes of the colon under a microscope by taking tissue specimens from serious lesion sites for HE staining. Meanwhile, colonic smooth muscle was isolated to observe the effect of muscimol, a receptor agonist of the GABA and GABA_A, bicuculline, an antagonist of the GABA_A, and baclofen, a receptor antagonist of the GABA_B on the isolated colonic smooth muscle using isometric tension as an indicator.

RESULTS: After four days of treatment with dextran sulfate 5000, the character of the stool of rats in the model group changed, with 30% of rats showing loose stool and 70% showing diarrhea. After six days, about 40% of rats had obvious bloody stool and an obvious decrease in activity and eating. In rats of the normal group, gross pathological examination revealed that the colon had no adhesion, the mucosa had mild hyperemia but no ulcers; microscopic pathological examination revealed intact tissue structure and regularly arranged glands. In rats of the model group, the number of glands decreased, the tissue structure was disorderly, the mucosa was erosive, bleeding, necrotic, and had large deep ulcers. Compared with the normal group, the DIA (3.83 ± 2.74 vs 1.23 ± 1.62, P < 0.05) and histopathologic score (2.52 ± 1.36 vs 0.41 ± 0.74, P < 0.05) were increased significantly in the model group. Treatment with GABA significantly inhibited the independent contraction activities of the isolated colonic smooth muscle from rats of both the normal and model groups (P < 0.05). Treatment with GABA at 0.01 mmol/L and 100 mmol/L resulted in inhibition rates of 20.00% ± 0.02% and 67.60% ± 0.03%, respectively, for the normal group, and 19.50% ± 0.02% and 64.50% ± 0.05% for the model group. There were no significant differences in the above inhibition rates between the two groups (P > 0.05). Treatment with 0.01 mmol/L bicuculline increased the contractile tension of the isolated colonic smooth muscle of the rats (1.25 g ± 0.03 g vs 0.77 g ± 0.04 g, P < 0.05), but treatment with 0.01 mmol/L muscimol or 0.01 mmol/L baclofen decreased the contractile tension significantly (0.38 g ± 0.03 g vs 0.75 g ± 0.06 g, P < 0.05; 0.45 g ± 0.05 g vs 0.75 g ± 0.04 g, P < 0.05).

CONCLUSION: GABA has inhibitory effects on the contraction of the isolated colonic smooth muscle of rats. There exist GABA_A and GABA_B in the isolated colonic smooth muscle of rats, and GABA has inhibitory effects on the muscle contraction when acting on GABA_A, but has stimulating effects when acting on GABA_B.