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Francis L, Capon F, Smith CH, Haniffa M, Mahil SK. Inflammatory memory in psoriasis: From remission to recurrence. J Allergy Clin Immunol 2024:S0091-6749(24)00506-2. [PMID: 38761994 DOI: 10.1016/j.jaci.2024.05.008] [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: 02/09/2024] [Revised: 05/13/2024] [Accepted: 05/14/2024] [Indexed: 05/20/2024]
Abstract
The routine use of targeted systemic immunomodulatory therapies has transformed outcomes for people with severe psoriasis, with skin clearance (clinical remission) rates up to 60% at 1 year of biologic treatment. However, psoriasis may recur following drug withdrawal, and as a result, patients tend to continue receiving costly treatment indefinitely. Here, we review research into the "inflammatory memory" in resolved psoriasis skin and the potential mechanisms leading to psoriasis recurrence following drug withdrawal. Research has implicated immune cells such as tissue resident memory T cells, Langerhans cells, and dermal dendritic cells, and there is growing interest in keratinocytes and fibroblasts. A better understanding of the interactions between these cell populations, enabled by single cell technologies, will help to elucidate the events underpinning the shift from remission to recurrence. This may inform the development of personalized strategies for sustaining remission while reducing long-term drug burden.
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Affiliation(s)
- Luc Francis
- St John's Institute of Dermatology, King's College London and Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Francesca Capon
- Department of Medical and Molecular Genetics, King's College London, London, United Kingdom
| | - Catherine H Smith
- St John's Institute of Dermatology, King's College London and Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Muzlifah Haniffa
- Wellcome Sanger Institute, Wellcome Genome Campus, Cambridge, United Kingdom; Biosciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom; Department of Dermatology and NIHR Newcastle Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Satveer K Mahil
- St John's Institute of Dermatology, King's College London and Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom.
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O'Connell DM, Moses J. Invited commentary to immunotherapy withdrawal by step-down to mesalamine in pediatrics patients with ulcerative colitis. JPGN REPORTS 2024; 5:95-96. [PMID: 38756131 PMCID: PMC11093890 DOI: 10.1002/jpr3.12047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/17/2023] [Accepted: 12/29/2023] [Indexed: 05/18/2024]
Affiliation(s)
- Daniel M. O'Connell
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and NutritionUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Jonathan Moses
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and NutritionStanford University School of MedicinePalo AltoCaliforniaUSA
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Szigeti R, Kellermayer R. Immunotherapy withdrawal by step-down to mesalamine in pediatric patients with ulcerative colitis. JPGN REPORTS 2024; 5:97-100. [PMID: 38756120 PMCID: PMC11093912 DOI: 10.1002/jpr3.12048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 12/04/2023] [Accepted: 01/14/2024] [Indexed: 05/18/2024]
Abstract
Objective Parents and pediatric patients with ulcerative colitis (UC) who progressed to systemic immunotherapy are concerned about lifelong risks from such treatments. There is limited knowledge about withdrawal of such agents and step-down (SD) to enteral 5-aminosalicylic acid (mesalamine) before transitioning to adult care. Methods We studied nine pediatric cases with moderate to severe UC who after a median of 2.18 years of clinical remission on systemic immunotherapy stepped down to oral mesalamine treatment. Results Average follow-up time from SD was 3.49 years. Five patients (55.5%) had sustained remission (without any flare noted) after SD during follow-up. Sustained clinical remission was 88.9% (8/9) at 1 year, 87.5% (7/8) at 2 years, and 66.7% (4/6) at 3 years after SD. Out of those tested (one patient was not tested), 62.5% (5/8) had fecal calprotectin <50 μg/g. Four out of six patients examined (66.6%) had mucosal healing on post-SD colonoscopy. Conclusion We propose that SD to mesalamine can be a reasonable therapeutic consideration for pediatric patients with UC before transitioning to adult gastroenterology care. Shared decision-making is important before such treatment changes.
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Affiliation(s)
- Reka Szigeti
- Department of Pathology and Genomic MedicineHouston Methodist HospitalHoustonTexasUSA
| | - Richard Kellermayer
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Texas Children's HospitalBaylor College of MedicineHoustonTexasUSA
- USDA/ARS Children's Nutrition Research CenterHoustonTexasUSA
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Gisbert JP, Chaparro M. De-escalation of Biologic Treatment in Inflammatory Bowel Disease: A Comprehensive Review. J Crohns Colitis 2024; 18:642-658. [PMID: 37943286 DOI: 10.1093/ecco-jcc/jjad181] [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: 09/04/2023] [Indexed: 11/10/2023]
Abstract
INTRODUCTION Biologic therapy is an effective treatment for inflammatory bowel disease [IBD]. However due to cost and safety concerns, dose de-escalation strategies after achieving remission have been suggested. AIM To critically review available data on dose de-escalation of biologics [or other advanced therapies] in IBD. We will focus on studies evaluating de-escalation to standard dosing in patients initially optimised, and also on studies assessing de-escalation from standard dosing. METHODS A systematic bibliographic search was performed. RESULTS The mean frequency of de-escalation after previous dose intensification [12 studies, 1,474 patients] was 34%. The corresponding frequency of de-escalation from standard dosing [five studies, 3,842 patients] was 4.2%. The relapse rate of IBD following anti-tumour necrosis factor [TNF] de-escalation to standard dosing in patients initially dose-escalated [10 studies, 301 patients] was 30%. The corresponding relapse rate following anti-TNF de-escalation from standard dosing [nine studies, 494 patients] was 38%. The risk of relapse was lower for patients in clinical, biologic, and endoscopic/radiological remission at the time of de-escalation. A role of anti-TNF therapeutic drug monitoring in the decision to dose de-escalate has been demonstrated. In patients relapsing after de-escalation, re-escalation is generally effective. De-escalation is not consistently associated with a better safety profile. The cost-effectiveness of the de-escalation strategy remains uncertain. Finally, there is not enough evidence to recommend dose de-escalation of biologics different from anti-TNFs or small molecules. CONCLUSIONS Any consideration for de-escalation of biologic therapy in IBD must be tailored, taking into account the risks and consequences of a flare and patients' preferences.
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Affiliation(s)
- Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa [IIS-Princesa], Universidad Autónoma de Madrid [UAM], Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBEREHD], Madrid, Spain
| | - María Chaparro
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa [IIS-Princesa], Universidad Autónoma de Madrid [UAM], Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBEREHD], Madrid, Spain
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Fenton CG, Ray MK, Paulssen RH. Challenges in Defining a Reference Set of Differentially Expressed lncRNAs in Ulcerative Colitis by Meta-Analysis. Curr Issues Mol Biol 2024; 46:3164-3174. [PMID: 38666928 PMCID: PMC11049510 DOI: 10.3390/cimb46040198] [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: 03/05/2024] [Revised: 03/27/2024] [Accepted: 04/03/2024] [Indexed: 04/28/2024] Open
Abstract
The study aimed to identify common differentially expressed lncRNAs from manually curated ulcerative colitis (UC) gene expression omnibus (GEO) datasets. Nine UC transcriptomic datasets of clearly annotated human colonic biopsies were included in the study. The datasets were manually curated to select active UC samples and controls. R packages geneknitR, gprofiler, clusterProfiler were used for gene symbol annotation. The R EdgeR package was used to analyze differential expression. This resulted in a total of nineteen lncRNAs that were differentially expressed in at least three datasets of the nine GEO datasets. Several of the differentially expressed lncRNAs found in UC were associated with promoting colorectal cancer (CRC) through regulating gene expression, epithelial to mesenchymal transition (EMT), cell cycle progression, and by promoting tumor proliferation, invasion, and migration. The expression of several lncRNAs varied between disease states and tissue locations within the same disease state. The identified differentially expressed lncRNAs may function as general markers for active UC independent of biopsy location, age, gender, or treatment, thereby representing a comparative resource for future comparisons using available GEO UC datasets.
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Affiliation(s)
- Christopher G. Fenton
- Clinical Bioinformatics Research Group, Department of Clinical Medicine, UiT-The Arctic University of Norway, N-9037 Tromsø, Norway; (C.G.F.); (M.K.R.)
- Genomic Support Centre Tromsø (GSCT), Department of Clinical Medicine, UiT-The Arctic University of Norway, N-9037 Tromsø, Norway
| | - Mithlesh Kumar Ray
- Clinical Bioinformatics Research Group, Department of Clinical Medicine, UiT-The Arctic University of Norway, N-9037 Tromsø, Norway; (C.G.F.); (M.K.R.)
| | - Ruth H. Paulssen
- Clinical Bioinformatics Research Group, Department of Clinical Medicine, UiT-The Arctic University of Norway, N-9037 Tromsø, Norway; (C.G.F.); (M.K.R.)
- Genomic Support Centre Tromsø (GSCT), Department of Clinical Medicine, UiT-The Arctic University of Norway, N-9037 Tromsø, Norway
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Selinger CP, Rosiou K, Lenti MV. Biological therapy for inflammatory bowel disease: cyclical rather than lifelong treatment? BMJ Open Gastroenterol 2024; 11:e001225. [PMID: 38341192 PMCID: PMC10870786 DOI: 10.1136/bmjgast-2023-001225] [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: 10/29/2023] [Accepted: 01/04/2024] [Indexed: 02/12/2024] Open
Abstract
Inflammatory bowel disease (IBD) treatment was revolutionised with the arrival of biological therapy two decades ago. There are now multiple biologics and increasingly novel small molecules licensed for the treatment of IBD. Treatment guidelines highlight the need for effective control of inflammation and early escalation to advanced therapies to avoid long-term complications. Consequently, a large proportion of patients with IBD receive advanced therapies for a long time. Despite their beneficial risk-benefit profile, these treatments are not without risk of side effects, are costly to healthcare providers and pose a burden to the patient. It is, therefore, paramount to examine in which circumstances a temporary cessation of therapy can be attempted without undue clinical risk. Some patients may benefit from cyclical rather than continuous treatment. This review examines the risk of relapse after discontinuation of advanced therapies, how to identify patients at the lowest risk of relapse and the chance of recapturing response when flaring after discontinuation.
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Affiliation(s)
| | - Konstantina Rosiou
- Department of Gastroenterology, St James's University Hospital, Leeds, UK
| | - Marco V Lenti
- Internal Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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Zeina T, Gandhi S, Mittal A, Levy AN, Weinstock J, Singh S, Jangi S. Predictors and Etiologies of Clinical Relapse Among Patients With Ulcerative Colitis in Deep Remission. J Clin Gastroenterol 2024; 58:195-199. [PMID: 36753459 PMCID: PMC10406966 DOI: 10.1097/mcg.0000000000001834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 01/03/2023] [Indexed: 02/09/2023]
Abstract
GOAL The objective of this study was to evaluate for potential predictors and etiologies of clinical relapse among patients with ulcerative colitis in deep remission. BACKGROUND Patients displaying deep (endoscopic and histologic) remission have a decreased cumulative risk of relapse in ulcerative colitis of <10% per year, but predictors and etiologies of relapse in this population are poorly understood. MATERIALS AND METHODS We performed a retrospective cohort study utilizing electronic medical records at Tufts Medical Center to identify patients in deep remission, classified as having both endoscopic remission (Mayo Endoscopic Score of 0 or 1) and histologic remission (Simplified Geboes Score 0.2). We evaluated the cumulative risk of clinical relapse following attainment of deep remission and examined predictors and etiologies of relapse. RESULTS Among 139 patients with ulcerative colitis in deep remission, the cumulative risk of relapse was <10% and <20% at 1 and 2 years. Patients with complete normalization of mucosa (Geboes=0) and normalization of C-reactive protein (<7.48 mg/dL) at the time of remission were associated with a lower risk of relapse. Discontinuation of therapy was the most commonly identified etiology of relapse. CONCLUSIONS Patients in deep remission have a 1-year risk of clinical relapse of <10%, with those demonstrating a non-normalized mucosa or elevated C-reactive protein predictive of persistent relapse risk. Discontinuation of therapy or minor histologic changes may drive relapse among those in deep remission.
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Affiliation(s)
- Tanya Zeina
- Division of Gastroenterology, Tufts Medical Center, Boston, MA, United States
| | - Shiv Gandhi
- Division of Gastroenterology, Tufts Medical Center, Boston, MA, United States
| | - Akaash Mittal
- Division of Gastroenterology, Tufts Medical Center, Boston, MA, United States
| | - Alexander N. Levy
- Division of Gastroenterology, Tufts Medical Center, Boston, MA, United States
| | - Joel Weinstock
- Division of Gastroenterology, Tufts Medical Center, Boston, MA, United States
| | - Siddharth Singh
- Division of Gastroenterology, University of California, La Jolla, CA, United States
| | - Sushrut Jangi
- Division of Gastroenterology, Tufts Medical Center, Boston, MA, United States
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Kitamoto S, Kamada N. The oral-gut axis: a missing piece in the IBD puzzle. Inflamm Regen 2023; 43:54. [PMID: 37932859 PMCID: PMC10626704 DOI: 10.1186/s41232-023-00304-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 10/17/2023] [Indexed: 11/08/2023] Open
Abstract
Inflammatory bowel disease (IBD) is a multifactorial intractable intestinal disease. Focusing on only one facet of the pathogenesis of IBD is insufficient to fully capture the complexity of the disease, and results in limited advance in clinical management. Therefore, it is critical to dissect the interactions amongst the multifarious contributors to the pathogenesis to comprehensively understand its pathology and subsequently improve clinical outcomes. In this context, the systemic interactions between organs, particularly the oral-gut axis mediated by host immune cells and resident microorganisms, have garnered significant attention in IBD research. More specifically, periodontal disease such as periodontitis has been implicated in augmenting intestinal inflammation beyond the confines of the oral cavity. There is mounting evidence suggesting that potentially harmful oral resident bacteria, termed pathobionts, and pro-inflammatory immune cells from the oral mucosa can migrate to the gastrointestinal tract, thereby potentiating intestinal inflammation. This article aims to provide a holistic overview of the causal relationship between periodontal disease and intestinal inflammation. Furthermore, we will discuss potential determinants that facilitate the translocation of oral pathobionts into the gut, a key event underpinning the oral-gut axis. Unraveling the complex dynamics of microbiota and immunity in the oral-gut continuum will lead to a better understanding of the pathophysiology inherent in both oral and intestinal diseases and the development of prospective therapeutic strategies.
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Affiliation(s)
- Sho Kitamoto
- The World Premier International Research Center (WPI) Immunology Frontier Research Center (IFReC), 1012 IFReC Research Building, Osaka University, 3-1 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Nobuhiko Kamada
- The World Premier International Research Center (WPI) Immunology Frontier Research Center (IFReC), 1012 IFReC Research Building, Osaka University, 3-1 Yamadaoka, Suita, Osaka, 565-0871, Japan.
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, 1150 West Medical Center Drive, Ann Arbor, MI, 48109, USA.
- Department of Pathology, University of Michigan, Ann Arbor, MI, 48109, USA.
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Gopalakrishnan S, Thomas R, Sedaghat S, Krishnakumar A, Khan S, Meyer T, Ajieren H, Nejati S, Wang J, Verma MS, Irazoqui P, Rahimi R. Smart capsule for monitoring inflammation profile throughout the gastrointestinal tract. BIOSENSORS & BIOELECTRONICS: X 2023; 14:100380. [PMID: 37799507 PMCID: PMC10552446 DOI: 10.1016/j.biosx.2023.100380] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
Inflammatory bowel disease (IBD) has become alarmingly prevalent in the last two decades affecting 6.8 million people worldwide with a starkly high relapse rate of 40% within 1 year of remission. Existing visual endoscopy techniques rely on subjective assessment of images that are error-prone and insufficient indicators of early-stage IBD, rendering them unsuitable for frequent and quantitative monitoring of gastrointestinal health necessary for detecting regular relapses in IBD patients. To address these limitations, we have implemented a miniaturized smart capsule (2.2 cm × 11 mm) that allows monitoring reactive oxygen species (ROS) levels as a biomarker of inflammation for quantitative and frequent profiling of inflammatory lesions throughout the gastrointestinal tract. The capsule is composed of a pH and oxidation reduction potential (ORP) sensor to track the capsule's location and ROS levels throughout the gastrointestinal tract, respectively, and an optimized electronic interface for wireless sensing and data communication. The designed sensors provided a linear and stable performance within the physiologically relevant range of the GI tract (pH: 1-8 and ORP: -500 to +500 mV). Additionally, systematic design optimization of the wireless interface electronics offered an efficient sampling rate of 10 ms for long-running measurements up to 48 h for a complete evaluation of the entire gastrointestinal tract. As a proof-of-concept, the capsule the capsule's performance in detecting inflammation risks was validated by conducting tests on in vitro cell culture conditions, simulating healthy and inflamed gut-like environments. The capsule presented here achieves a new milestone in addressing the emerging need for smart ingestible electronics for better diagnosis and treatment of digestive diseases.
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Affiliation(s)
- Sarath Gopalakrishnan
- School of Electrical and Computer Engineering, Purdue University, West Lafayette, IN, 47907, USA
- Birck Nanotechnology Center, Purdue University, West Lafayette, IN, 47907, USA
| | - Rithu Thomas
- School of Electrical and Computer Engineering, Purdue University, West Lafayette, IN, 47907, USA
| | - Sotoudeh Sedaghat
- Birck Nanotechnology Center, Purdue University, West Lafayette, IN, 47907, USA
- School of Materials Engineering, Purdue University, West Lafayette, IN, 47907, USA
| | - Akshay Krishnakumar
- School of Electrical and Computer Engineering, Purdue University, West Lafayette, IN, 47907, USA
- Birck Nanotechnology Center, Purdue University, West Lafayette, IN, 47907, USA
| | - Sadid Khan
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, MD, 21218, USA
| | - Trevor Meyer
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, MD, 21218, USA
| | - Hans Ajieren
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, MD, 21218, USA
| | - Sina Nejati
- Birck Nanotechnology Center, Purdue University, West Lafayette, IN, 47907, USA
- School of Materials Engineering, Purdue University, West Lafayette, IN, 47907, USA
| | - Jiangshan Wang
- Birck Nanotechnology Center, Purdue University, West Lafayette, IN, 47907, USA
- Department of Agricultural and Biological Engineering, West Lafayette, IN, 47907, USA
| | - Mohit S. Verma
- Birck Nanotechnology Center, Purdue University, West Lafayette, IN, 47907, USA
- Department of Agricultural and Biological Engineering, West Lafayette, IN, 47907, USA
- Weldon School of Biomedical Engineering, West Lafayette, IN, 47907, USA
| | - Pedro Irazoqui
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, MD, 21218, USA
| | - Rahim Rahimi
- School of Electrical and Computer Engineering, Purdue University, West Lafayette, IN, 47907, USA
- Birck Nanotechnology Center, Purdue University, West Lafayette, IN, 47907, USA
- School of Materials Engineering, Purdue University, West Lafayette, IN, 47907, USA
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Muth KN, Rech J, Losch FO, Hoerning A. Reversing the Inflammatory Process-25 Years of Tumor Necrosis Factor-α Inhibitors. J Clin Med 2023; 12:5039. [PMID: 37568441 PMCID: PMC10419406 DOI: 10.3390/jcm12155039] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/25/2023] [Accepted: 07/28/2023] [Indexed: 08/13/2023] Open
Abstract
Immune-mediated inflammatory diseases, such as rheumatoid arthritis, psoriatic arthritis, peripheral and/or axial spondyloarthritis, Crohn's disease, and ulcerative colitis, are characterized by molecular and cellular changes in the immune system. Due to the systemic nature of these diseases, organs such as the liver or cardiovascular system are often affected by the inflammatory process. Tumor necrosis factor-α inhibitor therapy reduces the activation of pro-inflammatory signaling cascades, mitigates the chronic inflammatory process by restoring cellular balance, and alleviates clinical consequences, such as pain and tissue damage.
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Affiliation(s)
| | - Juergen Rech
- Department of Internal Medicine III, Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Deutsches Zentrum Immuntherapie, Friedrich-Alexander-University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
| | | | - André Hoerning
- Deutsches Zentrum Immuntherapie, Friedrich-Alexander-University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Clinic for Children and Adolescent Medicine, Friedrich-Alexander-University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
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Parra RS, da Costa Ferreira S, Machado VF, Nigro CMC, da Rocha JJR, de Almeida Troncon LE, Feres O. Access to High-Cost Biological Agents: Perceptions of Brazilian Patients with Inflammatory Bowel Diseases. J Clin Med 2023; 12:jcm12072672. [PMID: 37048755 PMCID: PMC10095198 DOI: 10.3390/jcm12072672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/22/2023] [Accepted: 03/30/2023] [Indexed: 04/07/2023] Open
Abstract
Background and aims: Brazilian patients with inflammatory bowel diseases (IBD) requiring therapy with biological agents usually have access to medicines through the National Unified Health Care System (SUS). This study aimed to analyze Brazilian IBD patient perception regarding access (availability and provision quality) to high-cost drugs in the public health care system. Methods: A questionnaire-based survey was carried out in an IBD referral center in Brazil. All adult patients with an established diagnosis of ulcerative colitis (UC) or Crohn’s disease (CD) that use biological therapy were invited to participate. Data were collected on the biological in use, lack of distribution (number of absences, average time to regularization, impairment in patient treatment), and difficulties reported by patients in obtaining the drugs. Results: Overall, 205 patients met the inclusion criteria and answered the questionnaire. Most of the patients had CD (n = 161, 78.5%), nearly half of them (n = 104, 50.7%) were female; 87 patients (42.4%) were unemployed, and of these, 40 patients (19.5%) had government assistance as the main source of income. Regarding the medications used, infliximab (n = 128, 62.5%) was the most used medication, followed by adalimumab (n = 39, 19.0%). Most patients (n = 172, 83.9%) reported at least one failed delivery of biological medicine in the last year, with a single shortage in forty-two patients (24.4%), at least two shortages in forty-seven patients (27.3%), and three or more shortages in seventy-eight patients (45.3%). The average time to regularize the distribution was up to 1 month in 44 cases (25.6%), up to 2 months in 64 cases (37.2%), and more than 3 months in 56 patients (32.6%). Among patients who reported delays, 101 patients (58.7%) felt that it may have impaired their treatment. Conclusion: Brazilian IBD patients reported high rates of failure to dispense biological drugs by the national healthcare system within one year. Our data highlight the need for improvement in this system for the correct supply of medication to avoid treatment failure and relapse.
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Affiliation(s)
- Rogerio Serafim Parra
- Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto 14048-900, Brazil
| | - Sandro da Costa Ferreira
- Department of Clinical Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto 14048-900, Brazil
| | - Vanessa Foresto Machado
- Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto 14048-900, Brazil
| | - Cintia Maura Caseiro Nigro
- Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto 14048-900, Brazil
| | - José Joaquim Ribeiro da Rocha
- Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto 14048-900, Brazil
| | | | - Omar Feres
- Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto 14048-900, Brazil
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12
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Treatment withdrawal in Crohn's disease: slowly becoming clearer. Lancet Gastroenterol Hepatol 2023; 8:200-201. [PMID: 36640793 DOI: 10.1016/s2468-1253(22)00405-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 11/25/2022] [Indexed: 01/13/2023]
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13
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Nakase H, Esaki M, Hirai F, Kobayashi T, Matsuoka K, Matsuura M, Naganuma M, Saruta M, Tsuchiya K, Uchino M, Watanabe K, Hisamatsu T. Treatment escalation and de-escalation decisions in Crohn's disease: Delphi consensus recommendations from Japan, 2021. J Gastroenterol 2023; 58:313-345. [PMID: 36773075 PMCID: PMC10050046 DOI: 10.1007/s00535-023-01958-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 01/08/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND We aimed to develop criteria for treatment intensification in patients with (1) luminal Crohn's disease (CD), (2) CD with perianal disease and/or fistula, (3) CD with small bowel stenosis, (4) in the postoperative setting, and (5) for discontinuing or reducing the dose of treatment in patients with CD. METHODS PubMed and Embase were searched for studies published since 1998 which may be relevant to the five defined topics. Results were assessed for relevant studies, with preference given to data from randomized, controlled studies. For each question, a core panel of 12 gastroenterologists defined the treatment target and developed statements, based on the literature, current guidelines, and relevant additional studies. The evidence supporting each statement was graded using the Oxford Centre for Evidence-Based Medicine: Levels of Evidence (March 2009). A modified Delphi process was used to refine statements and gain agreement from 54 Japanese specialists at in-person and online meetings conducted between October 2020 and April 2021. RESULTS Seventeen statements were developed for treatment intensification in luminal CD (targeting endoscopic remission), six statements for treatment intensification in perianal/fistulizing CD (targeting healing of perianal lesions and complete closure of the fistula), six statements for treatment intensification in CD with small bowel stenosis (targeting resolution of obstructive symptoms), seven statements for treatment intensification after surgery (targeting endoscopic remission), and five statements for discontinuing or reducing the dose of treatment in patients with CD. CONCLUSIONS These statements provide guidance on how and when to intensify or de-intensify treatment for a broad spectrum of patients with CD.
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Affiliation(s)
- Hiroshi Nakase
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-Ku, Sapporo, Hokkaido 060-8543 Japan
| | - Motohiro Esaki
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Fumihito Hirai
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Taku Kobayashi
- Center for Advanced IBD Research and Treatment, Kitasato University, Kitasato Institute Hospital, Tokyo, Japan
| | - Katsuyoshi Matsuoka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Sakura Medical Center, Sakura, Chiba Japan
| | - Minoru Matsuura
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka-Shi, Tokyo, 181-8611 Japan
| | - Makoto Naganuma
- Division of Gastroenterology and Hepatology, The Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Masayuki Saruta
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Kiichiro Tsuchiya
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Motoi Uchino
- Division of Inflammatory Bowel Disease, Department of Gastroenterological Surgery, Hyogo Medical University, Nishinomiya, Hyogo Japan
| | - Kenji Watanabe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo Japan
| | - Tadakazu Hisamatsu
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka-Shi, Tokyo, 181-8611 Japan
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14
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Syal G, Melmed GY, Almario CV, Spiegel BMR. Azathioprine Withdrawal Is Cost-Effective in Patients with Crohn's Disease in Remission on Infliximab and Azathioprine. Dig Dis Sci 2023; 68:404-413. [PMID: 36512266 DOI: 10.1007/s10620-022-07789-x] [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: 04/04/2022] [Accepted: 12/05/2022] [Indexed: 02/09/2023]
Abstract
BACKGROUND In Crohn's disease, combination therapy with infliximab and azathioprine is more effective than either drug alone but is associated with a higher risk of therapy-related complications. Though therapy de-escalation can reduce risks and save costs, it is associated with a risk of Crohn's disease relapse. AIMS We aimed to study the cost-effectiveness of de-escalation strategies in Crohn's disease patients in remission on infliximab and azathioprine. METHODS We constructed a decision tree with Markov models for continuation of infliximab and azathioprine, discontinuation of azathioprine followed by its re-introduction in case of relapse, discontinuation of azathioprine followed by infliximab dose intensification without azathioprine reintroduction in case of relapse and discontinuation of infliximab. Third-party payers' perspective with a willingness-to-pay threshold of $100,000/quality-adjusted life years was used. Markov cycle length was 3 months, and the study period was 5 years. A 35-year-old patient with Crohn's disease in clinical remission on azathioprine 150 mg daily and infliximab 5 mg/kg every 8 weeks was used for base-case analysis. RESULTS Azathioprine withdrawal followed by its reintroduction upon relapse was the dominant strategy as it was the most effective and least expensive approach on base-case analysis. It was also cost-effective in 99.3% of Monte Carlo trial simulations. AZA withdrawal without IFX dose intensification upon relapse was the least effective and the most expensive strategy. CONCLUSION Azathioprine withdrawal is the most effective and least costly de-escalation strategy in CD patients in remission on combination therapy if AZA re-introduction is performed upon CD relapse.
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Affiliation(s)
- Gaurav Syal
- Division of Gastroenterology, University of California at San Diego, 9452 S Medical Ctr Dr, La Jolla, San Diego, CA, 92037, USA.
| | - Gil Y Melmed
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, 8730 Alden Drive, Second Floor East, Los Angeles, CA, 90048, USA
| | - Christopher V Almario
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Pacific Theaters Building, Suite 800, 116 N. Robertson Blvd., Los Angeles, CA, 90048, USA
| | - Brennan M R Spiegel
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Pacific Theaters Building, Suite 800, 116 N. Robertson Blvd., Los Angeles, CA, 90048, USA
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15
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Kwon Y, Kim YZ, Choe YH, Kim MJ. Increased monocyte abundance as a marker for relapse after discontinuation of biologics in inflammatory bowel disease with deep remission. Front Immunol 2022; 13:996875. [PMID: 36389755 PMCID: PMC9664214 DOI: 10.3389/fimmu.2022.996875] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 10/17/2022] [Indexed: 08/24/2023] Open
Abstract
Monocytes are involved in the upstream inflammatory process in the immune reaction in inflammatory bowel disease (IBD). Patients with IBD who discontinued biologics have been found to relapse, even after checking for deep remission. This study investigated whether monocytes could act as a predictor of relapse in patients who experienced relapse after the discontinuation of biologics. To this end, pediatric patients (<19 years old, n = 727) diagnosed with IBD from January 2003 to December 2021 were retrospectively reviewed. Clinical features, monocytes, and disease activity at the time of discontinuing biologics were evaluated by dividing patients into a relapsed group and a non-relapsed group after discontinuing biologics. The percentage of monocytes (8.65% vs. 6.42%, P < 0.001), the absolute monocyte count (614.79 cells/μL vs. 381.70 cells/μL, P < 0.001), and the monocyte/polymorphonuclear leukocyte (PMN) ratio (0.18 vs. 0.11, P < 0.001) at the time of discontinuation were significantly higher in patients who experienced relapse. As a result of multivariate analysis, the monocyte percentage (odds ratio: 2.012, P < 0.001) and monocyte/PMN ratio (odds ratio: 4.320E+14, P = 0.002) were evaluated as risk factors for relapse. Diagnostic capability was confirmed using area under operating characteristic curve (0.782) of the monocyte percentage for assessing the relapse within 6 months with cutoff value of 8.15% (P < 0.001). The findings presented in this study indicate that the patients with high monocyte counts experienced relapse after the discontinuation of biologics. A monocyte percentage of over 8.15% in the blood at the time of discontinuation was found to be associated with a high probability of relapse within 6 months, even in deep remission.
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Affiliation(s)
| | | | | | - Mi Jin Kim
- *Correspondence: Yon Ho Choe, ; Mi Jin Kim,
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16
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Lunasin protease inhibitor concentrate decreases pro-inflammatory cytokines and improves histopathological markers in dextran sodium sulfate-induced ulcerative colitis. FOOD SCIENCE AND HUMAN WELLNESS 2022. [DOI: 10.1016/j.fshw.2022.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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17
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Sung KY, Zhang B, Wang HE, Bai YM, Tsai SJ, Su TP, Chen TJ, Hou MC, Lu CL, Wang YP, Chen MH. Schizophrenia and risk of new-onset inflammatory bowel disease: a nationwide longitudinal study. Aliment Pharmacol Ther 2022; 55:1192-1201. [PMID: 35261051 DOI: 10.1111/apt.16856] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/16/2021] [Accepted: 02/16/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Inflammatory bowel disease (IBD) is a chronic gastrointestinal inflammatory disorder with increasing global prevalence. The risk of IBD in patients with schizophrenia remains unclear. We aim to investigate the risk of new-onset IBD in patients with schizophrenia compared with matched controls. METHODS We conducted a retrospective, population-based cohort study utilising patient data from the Taiwan National Health Insurance Research Database collected between January 1, 2001, and December 31, 2011. Patients diagnosed with schizophrenia by board-certified psychiatrists without prior diagnosis of IBD were enrolled and matched to controls in 1:4 fashion by age, sex, residence, income level and medical comorbidities. Adjusted hazard ratios (HRs) for new-onset IBD and sub-analyses were determined using Cox regression analysis with adjustments. RESULTS Among 116 164 patients with schizophrenia and 464 656 matched controls, overall incidence of IBD among patients was significantly higher (1.14% vs. 0.25%). Average age of IBD diagnosis was 46.82 among patients with schizophrenia, versus 55.30 among controls. The HR of developing IBD among patients was 3.28, with a 95% confidence interval (95% CI) 2.49-4.33. IBD risk was higher among patients with psychiatric admissions more than once per year (HR 7.99, 95% CI 5.25-12.15) compared to those hospitalised less frequently (HR 2.72, 95% CI 2.03-3.66). CONCLUSIONS This population-based cohort study demonstrates a significant association between schizophrenia and subsequent IBD development. Patients with schizophrenia develop IBD at a younger age, and the risk increases with inadequately controlled schizophrenia. Physician vigilance and awareness of this correlation will improve IBD diagnosis and management among this vulnerable patient population.
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Affiliation(s)
- Kuan-Yi Sung
- Endoscopy Center for Diagnosis and Treatment, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Bing Zhang
- Department of Medicine, Division of Gastrointestinal and Liver Disease, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Hohui E Wang
- Department of Psychiatry, University of California San Francisco, San Francisco, California, USA
| | - Ya-Mei Bai
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Psychiatry, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Jen Tsai
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Psychiatry, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tung-Ping Su
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Psychiatry, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Departments of Psychiatry and Medicine, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Tzeng-Ji Chen
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ming-Chih Hou
- Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ching-Liang Lu
- Endoscopy Center for Diagnosis and Treatment, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Institute of Brain Science, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yen-Po Wang
- Endoscopy Center for Diagnosis and Treatment, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Institute of Brain Science, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Mu-Hong Chen
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Psychiatry, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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18
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Cassinotti A, Corona A, Duca P, Nebuloni M, Maconi G, Fociani P, Ardizzone S. Noninvasive Monitoring After Azathioprine Withdrawal in Patients With Inflammatory Bowel Disease in Deep Remission. Clin Gastroenterol Hepatol 2021; 19:2293-2301.e1. [PMID: 34139332 DOI: 10.1016/j.cgh.2021.06.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 06/01/2021] [Accepted: 06/11/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There is uncertainty regarding the optimal duration of treatment with azathioprine (AZA) in ulcerative colitis (UC) and Crohn's disease (CD). We analyzed the clinical course and predictors of relapse after AZA withdrawal in patients in sustained deep remission. METHODS A prospective study was performed on patients who stopped their treatment with AZA while being in steroid-free, extended deep remission (normal clinical, endoscopic, and histologic indexes, C-reactive protein, and fecal calprotectin [FC]). Standard biochemical tests and FC were measured at 3 and 6 months, then every 6 months. Bowel ultrasounds and ileocolonoscopy were performed every 6 and 12 months, respectively. Multivariate analysis for predictors of relapse was performed using a Cox proportional hazards model and hazard ratios were calculated. Spearman nonparametric correlation test was also used. The accuracy of significant predictors was calculated. RESULTS Fifty-seven patients with inflammatory bowel disease stopped AZA after median 7 years (range, 5-19) and were followed up for median 50 months (range, 25-85). Twenty-six patients (18/31 UC, 8/26 CD; P = .003) relapsed, within a median 15 months (range, 2-37). FC was the only variable significantly correlated with later relapse of both diseases (UC: hazard ratio, 3.3; 95% confidence interval, 1.2-10; CD: hazard ratio, 4.5; 95% confidence interval, 1.4-12.5). The sensitivity, specificity, and positive and negative predictive values of FC were 50%, 100%, 100%, and 59% in UC and 50%, 94%, 80%, and 81% in CD. CONCLUSIONS More than half patients with UC and one-third of patients with CD relapse after AZA withdrawal despite previous deep remission. FC positivity is associated with high risk of relapse, allowing early correction of the therapeutic strategy.
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Affiliation(s)
- Andrea Cassinotti
- Gastroenterology Unit, "L. Sacco" University Hospital, ASST Fatebenefratelli Sacco, Milan, Italy; Gastroenterology and Digestive Endoscopy Unit, ASST Sette Laghi, Varese, Italy.
| | - Alberto Corona
- Accident and Emergency Department, Esine and Edolo Hospitals, ASST Vallecamonica, Vallecamonica, Italy
| | | | - Manuela Nebuloni
- Pathology Unit, Luigi Sacco University Hospital, ASST Fatebenefratelli Sacco, Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Milan, Italy
| | - Giovanni Maconi
- Gastroenterology Unit, "L. Sacco" University Hospital, ASST Fatebenefratelli Sacco, Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Milan, Italy
| | | | - Sandro Ardizzone
- Gastroenterology Unit, "L. Sacco" University Hospital, ASST Fatebenefratelli Sacco, Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Milan, Italy
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19
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Alipour O, Gualti A, Shao L, Zhang B. Systematic review and meta-analysis: real-world data rates of deep remission with anti-TNFα in inflammatory bowel disease. BMC Gastroenterol 2021; 21:312. [PMID: 34344314 PMCID: PMC8335971 DOI: 10.1186/s12876-021-01883-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 07/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Deep remission (DR) is a treatment target in IBD associated with reduced hospitalization and improved outcome. Randomized control trial (RCT) data demonstrates efficacy of anti-TNFα agents in achieving DR; however, real-world data (RWD) can provide information complementary to RCTs, specifically regarding treatment duration. In this systematic review with meta-analysis, we use real-world data (RWD) to determine rates of DR in IBD treated with anti-TNFα. METHODS We completed a systematic search of MEDLINE and EMBASE on July 8, 2019 with review of major gastrointestinal conference abstracts from 2012 to 2019. Studies utilizing RWD (data not from phase I-III RCTs) of adult IBD patients treated with anti-TNFα agents were included. DR was defined by clinical and endoscopic remission at minimum. DR was assessed at 8 weeks, 6 months, 1 year, and 2 years. Risk of bias was assessed with the Newcastle Ottawa Scale. RESULTS 29,033 publications were identified. Fifteen publications, nine manuscripts and six conference abstracts, were included encompassing 1212 patients (769 Crohn's disease-CD, 443 ulcerative colitis-UC), and analyzed using Comprehensive Meta-Analysis. Rate of DR was 36.4% (95% CI 12.6-69.4%) at 8 weeks, 39.1% (95% CI 10.4-78%) at 6 months, 44.4% (95% CI 34.6-54.6%) at 1 year, and 36% (95% CI 18.7-58%) at 2 years. DR in CD at 1 year was 48.6% (95% CI 32.8-64.7%) and in UC was 43.6% (95% CI 32.8-55.1%). CONCLUSIONS The rate of DR was highest after 1 year of therapy, in nearly 45% of IBD patients treated with anti-TNFα. Similar rates were achieved between patients with UC and CD. The findings highlight the efficacy of anti-TNFα in real-world setting. Future studies using RWD can determine efficacy of newer IBD therapeutics in routine clinical practice.
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Affiliation(s)
- Omeed Alipour
- Department of Medicine, Division of Gastroenterology, University of Washington, 1959 NE Pacific Street, Box 356424, Seattle, WA 98195 USA
| | - Alakh Gualti
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California San Francisco – Fresno, 155 N Fresno Street, Fresno, CA 93721 USA
| | - Ling Shao
- Department of Medicine, Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, 2011 Zonal Avenue, HMR 101, Los Angeles, CA 90033 USA
| | - Bing Zhang
- Department of Medicine, Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, 2011 Zonal Avenue, HMR 101, Los Angeles, CA 90033 USA
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California San Francisco, 513 Parnassus Avenue, Room S-237, San Francisco, CA 94143 USA
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20
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Privitera G, Pugliese D, Lopetuso LR, Scaldaferri F, Neri M, Guidi L, Gasbarrini A, Armuzzi A. Novel trends with biologics in inflammatory bowel disease: sequential and combined approaches. Therap Adv Gastroenterol 2021; 14:17562848211006669. [PMID: 33995579 PMCID: PMC8082976 DOI: 10.1177/17562848211006669] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 03/11/2021] [Indexed: 02/04/2023] Open
Abstract
Inflammatory bowel disease (IBD) management has changed dramatically over the past 20 years, after the introduction of targeted biological therapies. However, the impact of these new drugs in changing the natural history of disease is still under debate. Recent evidence seems to suggest that the extent of their efficacy might be, at least partially, dependent on the timing of their introduction and on the subsequent management strategy. In this complex landscape, the potential role for a more dynamic approach with treatments based on sequencing and combining targeted therapies has been explored only minimally so far. In this review, we aim to explore the potential biological rationale behind the use of sequential and combination therapies in IBD, to summarise the current knowledge on this topic and to propose a management algorithm that combines these notions.
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Affiliation(s)
- Giuseppe Privitera
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Daniela Pugliese
- CEMAD – IBD UNIT – Unità Operativa Complessa di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario ‘A. Gemelli’ IRCCS, Rome, Italy
| | - Loris Riccardo Lopetuso
- CEMAD – IBD UNIT – Unità Operativa Complessa di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario ‘A. Gemelli’ IRCCS, Rome, Italy,Department of Medicine and Ageing Sciences, ‘G. d’Annunzio’ University of Chieti-Pescara, Chieti, Italy,Center for Advanced Studies and Technology (CAST), ‘G. d’Annunzio’ University of Chieti-Pescara, Chieti, Italy
| | - Franco Scaldaferri
- CEMAD – IBD UNIT – Unità Operativa Complessa di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario ‘A. Gemelli’ IRCCS, Rome, Italy
| | - Matteo Neri
- Department of Medicine and Ageing Sciences, ‘G. d’Annunzio’ University of Chieti-Pescara, Chieti, Italy,Center for Advanced Studies and Technology (CAST), ‘G. d’Annunzio’ University of Chieti-Pescara, Chieti, Italy
| | - Luisa Guidi
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy,CEMAD – IBD UNIT – Unità Operativa Complessa di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario ‘A. Gemelli’ IRCCS, Rome, Italy
| | - Antonio Gasbarrini
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy,CEMAD – IBD UNIT – Unità Operativa Complessa di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario ‘A. Gemelli’ IRCCS, Rome, Italy
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21
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Jangi S, Holmer AK, Dulai PS, Boland BS, Collins AE, Pham L, Sandborn WJ, Singh S. Risk of Relapse in Patients With Ulcerative Colitis With Persistent Endoscopic Healing: A Durable Treatment Endpoint. J Crohns Colitis 2021; 15:567-574. [PMID: 32914194 PMCID: PMC8023862 DOI: 10.1093/ecco-jcc/jjaa184] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Deep remission in patients with UC has relied on initial achievement of biochemical, endoscopic, and/or histological remission. We evaluated persistent symptomatic remission and endoscopic healing (EH: Mayo endoscopy score [MES] 0 or 1) on consecutive endoscopic examinations as a durable treatment endpoint. METHODS In a retrospective cohort study, we estimated and compared cumulative risk of clinical relapse in patients with persistent EH, with and without persistent histological remission and depth of EH, among adults with active UC treated-to-target of symptomatic remission and EH who achieved and maintained symptomatic remission and EH over two serial endoscopic assessments. We also explored risk of relapse in patients with persistent EH whose therapy was de-escalated. RESULTS Of 270 patients who initially achieved EH with treatment-to-target, 89 maintained symptomatic remission and EH on follow-up endoscopy [interval between EH1 and EH2, 16 months]. On follow-up after EH2 [median, 19 months], 1-year cumulative risk of relapse in patients with persistent EH was 11.5%, and with persistent histological remission was 9.5%. Seventeen patients with persistent EH, who underwent de-escalation of therapy, did not have an increased risk of relapse as compared with patients who continued index therapy [5.3% vs 14%, p = 0.16]. CONCLUSIONS Patients with active UC treated-to-target of clinical remission, who achieve and maintain symptomatic remission and EH over consecutive endoscopies, have a low risk of relapse, particularly in a subset of patients who simultaneously achieve histological remission. Persistent EH should be examined as a treatment endpoint suggestive of deep remission.
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Affiliation(s)
- Sushrut Jangi
- Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Ariela K Holmer
- Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Parambir S Dulai
- Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Brigid S Boland
- Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Angelina E Collins
- Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Lysianne Pham
- Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - William J Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
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22
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Feitosa MR, Parra RS, de Camargo HP, Ferreira SDC, Troncon LEDA, da Rocha JJR, Féres O. COVID-19 quarantine measures are associated with negative social impacts and compromised follow-up care in patients with inflammatory bowel disease in Brazil. Ann Gastroenterol 2020; 34:39-45. [PMID: 33414620 PMCID: PMC7774653 DOI: 10.20524/aog.2020.0558] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 07/17/2020] [Indexed: 12/12/2022] Open
Abstract
Background COVID-19 has affected the entire world. We aimed to determine the impact of COVID-19 containment measures on the daily life and follow up of patients with inflammatory bowel disease (IBD). Methods During May 2020, we evaluated 179 (79.6%) patients with Crohn’s disease (CD) and 46 (20.4%) with ulcerative colitis (UC) by telephone, using a structured questionnaire to gather information on social impact and IBD follow up. Results Some kind of social distancing measure was reported by 95.6% of our patients, self-quarantine (64.9%) being the most frequent. Depressive mood was the most prevalent social impact (80.2%), followed by anxiety/fear of death (58.2%), insomnia (51.4%), daily activity impairment (48%), sexual dysfunction (46.2%), and productivity impairment (44%). The results were similar when we compared patients with active disease to those in remission and patients with UC to those with CD. Analysis of IBD follow up showed that 83.1% of all patients missed an IBD medical appointment, 45.5% of the patients missed laboratory tests, 41.3% missed the national flu vaccination program, 31.3% missed any radiologic exam, 17.3% missed colonoscopy, and 16.9% failed to obtain biologic therapy prescriptions. Biologics were discontinued by 28.4% of the patients. UC patients had higher rates of missed vaccination than CD patients (56.5% vs. 37.4%, P=0.02) and more failures to obtain a biologic prescription (28.3% vs. 14.0%, P=0.02). Conclusions Our study reveals alarming social impacts and declining follow-up care for IBD patients during the COVID-19 outbreak. These findings may have implications for disease control in the near future.
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Affiliation(s)
- Marley Ribeiro Feitosa
- Department of Surgery and Anatomy (Marley Ribeiro Feitosa, Rogério Serafim Parra, Hugo Parra de Camargo, José Joaquim Ribeiro da Rocha, Omar Féres)
| | - Rogério Serafim Parra
- Department of Surgery and Anatomy (Marley Ribeiro Feitosa, Rogério Serafim Parra, Hugo Parra de Camargo, José Joaquim Ribeiro da Rocha, Omar Féres)
| | - Hugo Parra de Camargo
- Department of Surgery and Anatomy (Marley Ribeiro Feitosa, Rogério Serafim Parra, Hugo Parra de Camargo, José Joaquim Ribeiro da Rocha, Omar Féres)
| | - Sandro da Costa Ferreira
- Department of Clinical Medicine (Sandro da Costa Ferreira, Luiz Ernesto de Almeida Troncon), Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, State of São Paulo, Brazil
| | - Luiz Ernesto de Almeida Troncon
- Department of Clinical Medicine (Sandro da Costa Ferreira, Luiz Ernesto de Almeida Troncon), Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, State of São Paulo, Brazil
| | - José Joaquim Ribeiro da Rocha
- Department of Surgery and Anatomy (Marley Ribeiro Feitosa, Rogério Serafim Parra, Hugo Parra de Camargo, José Joaquim Ribeiro da Rocha, Omar Féres)
| | - Omar Féres
- Department of Surgery and Anatomy (Marley Ribeiro Feitosa, Rogério Serafim Parra, Hugo Parra de Camargo, José Joaquim Ribeiro da Rocha, Omar Féres)
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