Safety and efficacy of adalimumab in pediatric patients with Crohn disease

Inflammatory Bowel Disease in Children: Current Diagnosis and Treatment Strategies

Pediatric inflammatory bowel disease (PIBD), including Crohn's disease and ulcerative colitis, has emerged as a significant global health challenge with rising incidence rates. Unlike adult inflammatory bowel disease, PIBD presents complexities, including growth impairment, nutritional deficiencies, and psychosocial challenges that necessitate tailored management strategies. This article reviews current diagnostic and emerging treatment strategies to highlight the evolution from traditional therapies such as aminosalicylates, corticosteroids, and immunomodulators to advanced biologic agents like infliximab and adalimumab. Emerging biological therapies, including vedolizumab and ustekinumab, show promise, while novel small molecule therapies such as Janus kinase (JAK) inhibitors are under investigation for potential use in the pediatric population. Supportive treatments, including exclusive enteral nutrition, modified diets, and probiotics, play a critical role in comprehensive disease management. Stem cell therapy and fecal microbiota transplant represent innovative approaches still under clinical evaluation. The review underscores the significance of holistic care, incorporating mind-body interventions and psychosocial support to improve patient quality of life. Key challenges persist, such as infection risks associated with long-term biological therapy use, gaps in pediatric-specific guidelines, and the limited inclusion of children in clinical trials. Future recommendations emphasize the importance of structured transition programs bridging pediatric and adult care, regular updates to clinical guidelines, and the integration of precision medicine to personalize treatment plans. Continued research and collaboration are essential for advancing the understanding and management of PIBD, ensuring that pediatric patients benefit from the most effective, evidence-based care available.

Adalimumab in Pediatric Inflammatory Bowel Disease

The introduction of biological agents with strong anti-inflammatory action, such as antitumor necrosis factor (TNF) agents, has changed inflammatory bowel disease (IBD) treatment strategy and goals, and has contributed significantly to improve the long-term prognosis of patients. Moreover, several biological agents are being used or researched in pediatric populations. However, only two biological agents, infliximab (IFX) and adalimumab (ADL), are currently approved for children and adolescents. In pediatric IBD, there are limitations and burdens associated with facilitating mucosal healing (MH) when utilizing these two biological agents. ADL is effective in both naïve patients and those with previous experience with biologics. Beyond clinical remission, this drug is also effective for MH and histological remission. The use of therapeutic drug monitoring to further enhance the effectiveness of ADL treatment can be expected to reduce treatment failure of ADL and pave the way for appropriate treatment in the treat-to-target era. This review paper focuses on ADL, examine studies conducted in children, and determine the role this agent plays against pediatric inflammatory bowel disease.

Vaccines in Children with Inflammatory Bowel Disease: Brief Review

Incidence of inflammatory bowel diseases (IBDs), including Crohn's disease (CD) and ulcerative colitis (UC), is increasing worldwide. Children with IBDs have a dysfunctional immune system and they are frequently treated with immunomodulating drugs and biological therapy, which significantly impair immune system functions and lead to an increased risk of infections. Vaccines are essential to prevent at least part of these infections and this explains why strict compliance to the immunization guidelines specifically prepared for IBD patients is strongly recommended. However, several factors might lead to insufficient immunization. In this paper, present knowledge on the use of vaccines in children with IBDs is discussed. Literature review showed that despite a lack of detailed quantification of the risk of infections in children with IBDs, these children might have infections more frequently than age-matched healthy subjects, and at least in some cases, these infections might be even more severe. Fortunately, most of these infections could be prevented when recommended schedules of immunization are carefully followed. Vaccines given to children with IBDs generally have adequate immunogenicity and safety. Attention must be paid to live attenuated vaccines that can be administered only to children without or with mild immune system function impairment. Vaccination of their caregivers is also recommended. Unfortunately, compliance to these recommendations is generally low and multidisciplinary educational programs to improve vaccination coverage must be planned, in order to protect children with IBD from vaccine-preventable diseases.

Biological therapy in pediatric age

Biological therapies, especially blocking tumor necrosis factor-α (TNFα) agents have radically changed the therapeutic approach and disease course of pediatric inflammatory bowel disease (IBD). In particular, drugs such as infliximab (IFX) and adalimumab (ADA) have been demonstrated to be effective in inducing and maintaining corticosteroid-free remission in both adult and pediatric patients with Crohns Disease (CD) and Ulcerative colitis (UC). Biosimilar biological (BioS) therapy is increasingly being used in pediatric age even though most knowledge on the safety and efficacy of these agents is based on IFX in adult IBD data. Studies show high rates of clinical response and remission in both IFX naïve patients and in patients switched from originator to BioS with similar risks of adverse events (AEs) as those reported with IFX originator. In the present review indications, efficacy and AEs of biological therapy in pediatric IBD will be discussed, as well as the role of other biological agents such as Golimumab, Vedolizumab and Ustekinumab, the role of BioS biological therapy and utility of therapeutic drug monitoring in clinical practice.

Efficacy of adalimumab as second-line therapy in a pediatric cohort of Crohn's disease patients who failed infliximab therapy: the Italian Society of Pediatric Gastroenterology, Hepatology, and Nutrition experience

Background

Adalimumab (Ada) treatment is an available option for pediatric Crohn’s disease (CD) and the published experience as rescue therapy is limited.

Objectives

We investigated Ada efficacy in a retrospective, pediatric CD cohort who had failed previous infliximab treatment, with a minimum follow-up of 6 months.

Methods

In this multicenter study, data on demographics, clinical activity, growth, laboratory values (CRP) and adverse events were collected from CD patients during follow-up. Clinical remission (CR) and response were defined with Pediatric CD Activity Index (PCDAI) score ≤10 and a decrease in PCDAI score of ≥12.5 from baseline, respectively.

Results

A total of 44 patients were consecutively recruited (mean age 14.8 years): 34 of 44 (77%) had active disease (mean PCDAI score 24.5) at the time of Ada administration, with a mean disease duration of 3.4 (range 0.3–11.2) years. At 6, 12, and 18 months, out of the total of the enrolled population, CR rates were 55%, 78%, and 52%, respectively, with a significant decrease in PCDAI scores (P<0.01) and mean CRP values (mean CRP 5.7 and 2.4 mL/dL, respectively; P<0.01) at the end of follow-up. Steroid-free remission rates, considered as the total number of patients in CR who were not using steroids at the end of this study, were 93%, 95%, and 96% in 44 patients at 6, 12, and 18 months, respectively. No significant differences in growth parameters were detected. In univariate analysis of variables related to Ada efficacy, we found that only a disease duration >2 years was negatively correlated with final PCDAI score (P<0.01). Two serious adverse events were recorded: 1 meningitis and 1 medulloblastoma.

Conclusion

Our data confirm Ada efficacy in pediatric patients as second-line biological therapy after infliximab failure. Longer-term prospective data are warranted to define general effectiveness and safety in pediatric CD patients.

Efficacy and Safety of Adalimumab for Paediatric Crohn's Disease: A Systematic Review

BACKGROUND AND AIM

Adalimumab is well-established therapy for adults with Crohn's disease [CD]. The aim of the study was to systematically assess the published evidence on the efficacy and safety of adalimumab for Crohn's disease in children.

METHODS

MEDLINE, EMBASE, the Cochrane Library, and abstracts from the main gastroenterological meetings in the past 5 years were systematically searched up to July 2015 for randomised controlled trials and observational studies on the efficacy and safety of adalimumab for Crohn's treatment in children and adolescents.

RESULTS

A total of 14 studies [1 randomised controlled trial, 13 case series], altogether including 664 patients [age: 1.9 to 21 years] were available for analysis. The studies differed with respect to patients' characteristics, including percentage of infliximab-naïve patients, disease duration, site of the disease, adalimumab doses, treatment duration, and follow-up period. The pooled remission rates were: 30% [n = 93/309] at 4 weeks, 54% [n = 79/145] at 3 months, 45% [n = 18/40] at 4 months, 42% [n = 146/345] at 6 months, 57% [n = 20/35] at 8 months, and 44% [n = 169/383] at 12 months. Of the total patients, 6% [n = 13/207] were classified as primary non-responders and 12% [n = 69/599] had severe adverse events reported including 2 deaths and 1 medulloblastoma. Withdrawal rate due to adverse events reported in one study was 35% [n = 64/182].

CONCLUSION

According to low-quality evidence based mainly on case series, approximately half of children with Crohn's disease on adalimumab therapy achieve remission during the first year of the therapy with reasonable safety profile. There is still a need for high-quality evidence on effectiveness and safety of adalimumab for paediatric Crohn's disease.

Adalimumab for the treatment of pediatric Crohn's disease

Inflammatory bowel diseases are characterized by a chronic relapsing course, high morbidity and impaired quality of life. Their incidence is rising, and about 25% of cases are diagnosed in pediatric age. Anti-TNF-α antibodies, such as infliximab and adalimumab (ADA), are usually administered in patients refractory to conventional therapies. However, increasing evidence suggests that they can be introduced earlier in the course of the disease, especially in patients with aggressive and extensive disease since diagnosis. ADA is a fully human anti-TNF-α antibody recently approved for pediatric Crohn's disease not only in patients unresponsive to infliximab, but also as a first-line anti-TNF-α therapy. In this review, we aim to summarize the current knowledge on the use of ADA in pediatric Crohn's disease and to discuss open issues regarding safety as well as future perspectives.

Growth and bone health in paediatric patients with Crohn's disease receiving subcutaneous tumor necrosis factor antibody

AIM: To study whether adalimumab (ADA) was associated with improvement in growth, bone mineral density (BMD) and bone metabolism.

METHODS: In children with Crohn’s disease (CD) there is a high prevalence of growth failure and reduced BMD. Treatment with infliximab is associated with an improvement in growth. Anthropometry, paediatric CD activity index (PCDAI), bone markers and BMD was measured in 18 patients (72% females) one year before and after start of ADA with a median age of 14.4 years (range: 5-19 years) at treatment start. Outcomes were indicators of growth with treatment as well as interval growth.

RESULTS: Eleven (61%) children experienced catch-up growth after ADA. PCDAI significantly decreased from 52.1 ± 16 to 30.4 ± 23 (P≤ 0.001). Post ADA, body mass index (BMI) standard deviation score (SDS) 0.1[range: 2.7-(-0.8)] vs -1 [range: 0.1-(-3.6)], P = 0.04 and ∆BMI SDS in children 0.3 [range: 0.7-(-0.2)] vs -1.1 [range: 1.2-(-2.3)], P = 0.01 in remission were significantly higher compared to those with moderate to severe inflammation. The main predictors for growth were 25-hydroxycholecalciferol and for bone mineralisation weight and height SDS. ADA had no significant influence on bone markers and BMD.

CONCLUSION: Next to improvement of PCDAI, half of the children achieved a positive catch-up growth. A better nutritional status with improvement in BMI and weight is positive predictor for improved growth and bone mineralisation.

Efficacy and safety of adalimumab after infliximab failure in pediatric Crohn disease

OBJECTIVES

The objective of the present study was to evaluate the effectiveness and safety of adalimumab (ADA) in children with Crohn disease (CD) who experienced infliximab (IFX) failure at the population level.

METHODS

The present retrospective study included all of the children with CD from a pediatric-onset population-based cohort who received ADA before 18 years because of IFX failure or intolerance. Efficacy of ADA was evaluated using the physician's global assessment score, C-reactive protein and orosomucoid, and nutritional and growth indicators.

RESULTS

A total of 27 children with CD received ADA. Median age at CD diagnosis and at ADA initiation was 11 years (Q1 = 9; Q3 = 12) and 15 years (12; 15), respectively. After a median follow-up of 16 (8; 26) months after ADA initiation, ADA had clinical benefit as measured by the physical global assessment score in 19 patients (70%). Cumulative probability of failure to ADA treatment was 38% at 6 months and 55% at 1 year. Eight patients had a primary failure (30%) and 5 of 19 (26%) a secondary failure to ADA. Furthermore, 11 patients (40%) experienced a total of 19 adverse effects. No serious adverse effects were observed and none resulted in ADA discontinuation. There was no significant change in growth and nutritional patterns during the study period, but we found a significant decrease in median C-reactive protein (15 mg/L [4; 44] vs 9 mg/L [3; 19]; P = 0.05) and orosomucoid (1.6 g/L [1.5; 2.6] vs 1.1 g/L [0.8; 1.9]; P = 0.001) from ADA initiation to maximal follow-up in patients responding to ADA.

CONCLUSIONS

In the present population-based cohort of pediatric-onset CD with IFX failure, treatment with ADA was safe and effective in two-thirds of patients.

Difficult-to-treat-pediatric Crohn's disease: focus on adalimumab

Adalimumab is a fully humanized anti-tumor necrosis factor alpha monoclonal antibody that was recently granted regulatory approval in the USA for the treatment of moderate to severe Crohn’s disease (CD) in children. Like infliximab, the first biologic agent used to treat pediatric CD, regulatory approval was secured many years following approval for adults. The long delay between adult and pediatric approval has led to many years of off-label use of adalimumab, although it is anticipated that the use of adalimumab may further increase with official regulatory approval. To date, pediatric literature on the use of adalimumab for treatment of CD is limited, and pediatric practitioners have mostly extrapolated from research and experience provided by the adult literature. The aim of this paper is to review the literature regarding adalimumab for the treatment of pediatric CD, and includes a review of landmark adult studies as well as the pivotal pediatric study that facilitated regulatory approval. We also discuss the role of anti-tumor necrosis factor alpha agents including adalimumab in the current treatment paradigm for pediatric CD.

The development and assessment of biological treatments for children

The development of biological agents with specific immunological targets has revolutionized the treatment of a wide variety of paediatric diseases where traditional immunosuppressive agents have been partly ineffective or intolerable. The increasing requirement for pharmaceutical companies to undertake paediatric studies has provided impetus for studies of biologics in children. The assessment of biological agents in children to date has largely relied upon randomized controlled trials using a withdrawal design, rather than a parallel study design. This approach has been largely used due to ethical concerns, including use of placebo treatments in children with active chronic disease, and justified on the basis that treatments have usually already undergone robust assessment in related adult conditions. However, this study design limits the reliability of the data and can confuse the interpretation of safety results. Careful ongoing monitoring of safety and efficacy in real-world practice through national and international biologics registries and robust reporting systems is crucial. The most commonly used biological agents in children target tumour necrosis factor-α, interleukin-1, interleukin-6 and cytotoxic lymphocyte-associated antigen-4. These agents are most frequently used in paediatric rheumatic diseases. This review discusses the development and assessment of biologics within paediatric rheumatology with reference to the lessons learned from use in other subspecialties.

Risks of serious infection or lymphoma with anti-tumor necrosis factor therapy for pediatric inflammatory bowel disease: a systematic review

BACKGROUND & AIMS

Many physicians hesitate to recommend anti-tumor necrosis factor (TNF) therapy for pediatric patients with inflammatory bowel disease (IBD) because of concerns about risk of infection and cancer. We performed a systematic review to quantify the incidence of serious infection, lymphoma, and death among pediatric patients with IBD who received anti-TNF therapy. These values were compared with those expected from other treatments, from adults with IBD, and from the general pediatric population.

METHODS

We searched MEDLINE, EMBASE, the Cochrane Collaboration, and Web of Knowledge for studies of infliximab therapy for children with ulcerative colitis or Crohn's disease, or adalimumab therapy for children with Crohn's disease. Standardized incidence ratios (SIRs) were calculated, comparing rates of infection and cancer among pediatric patients exposed to anti-TNF agents vs expected rates from pediatric patients not exposed to anti-TNF therapies or adult patients exposed to anti-TNF agents. Our analysis included 5528 patients with 9516 patient-years of follow-up evaluation (PYF).

RESULTS

The rate of serious infections among pediatric patients treated with anti-TNF agents (352/10,000 PYF) was similar to that of pediatric patients who received immunomodulator monotherapy (333/10,000 PYF; SIR, 1.06; 95% confidence interval [CI], 0.83-1.36), but significantly lower than the expected rate for pediatric patients treated with steroids (730/10,000 PYF; SIR, 0.48; 95% CI, 0.40-0.58) or adults treated with anti-TNF agents (654/10,000 PYF; SIR, 0.54; 95% CI, 0.43-0.67). Five treatment-related deaths occurred (4 from sepsis and 1 from arrhythmia). Two patients developed lymphoma (2.1/10,000 PYF). This value was similar to the expected rate of lymphoid neoplasia in the entire pediatric population (5.8/100,000 PYF; SIR, 3.5; 95% CI, 0.35-19.6), and lower than the population of pediatric patients receiving thiopurine monotherapy (4.5/10,000 PYF; SIR, 0.47; 95% CI, 0.03-6.44), and among adults treated with anti-TNF agents (6.1/10,000 PYF; SIR, 0.34; 95% CI, 0.04-1.51).

CONCLUSIONS

Based on a systematic review, the risk of lymphoma was no greater among children with IBD who received anti-TNF therapy than those treated with other IBD therapies or adults treated with anti-TNF agents. The rate of serious infection was significantly lower among pediatric patients with IBD treated with anti-TNF agents than those treated with steroids, or adults with IBD who received anti-TNF therapy.

Mucosal healing in pediatric Crohn's disease after anti-TNF therapy: a long-term experience at a single center

PURPOSE

The anti-tumor necrosis factor (TNF) agents infliximab (IFX) and adalimumab (ADA) have been recently introduced to treat severe inflammatory bowel disease (IBD) that is unresponsive to other drugs. Several studies have confirmed the safety and efficacy of these agents for adult IBD patients, whereas there is less data on pediatric IBD. Mucosal healing, associated with fewer complications and surgeries, is considered the goal of treatment by some authors. The objective of this study was to evaluate the safety and efficacy (in terms of endoscopic, clinical, and laboratoristic response) of IFX and ADA in a cohort of pediatric patients with Crohn's disease (CD).

METHODS

We conducted a retrospective analysis of prospectively collected data; we studied 33 patients (20 male, 13 female) with a diagnosis of CD established before 18 years of age: 29/33 were treated with IFX and 19/33 received ADA (four of them were naive to IFX). We evaluated clinical, endoscopic, and laboratoristic response to IFX and ADA for each patient and recorded the adverse effects of these drugs.

RESULTS

With regard to IFX treatment, 22.2% of patients achieved mucosal healing and 44.4% showed an endoscopic response. With regard to ADA therapy, 25% of patients achieved mucosal healing and 50% showed an endoscopic response. Overall clinical response rates for IFX and ADA were 84 and 92.3%, respectively. Both drugs were well tolerated.

CONCLUSION

To our knowledge, this is the first study reporting mucosal healing after ADA therapy in pediatric CD. We found significant mucosal healing and response rates in our group of patients. Compared with other pediatric studies, we reported similar clinical response rates and longer follow-up of patients.

Balancing and communicating the risks and benefits of biologics in pediatric inflammatory bowel disease

: Anti-tumor necrosis factor agents are now considered to be a vital component of the treatment algorithm for pediatric inflammatory bowel disease. Despite the clear benefit of these agents and the realignment of treatment goals to achieve early mucosal healing, the decision to initiate therapy is often delayed due to uncertainties regarding risks and benefits. The purpose of this review was to summarize the currently available data regarding anti-tumor necrosis factor agents in pediatric inflammatory bowel disease. Specifically, we review their expected efficacy in both Crohn's disease and ulcerative colitis and the likelihood of side effects associated with these agents. In addition, we address the barriers physicians face when communicating these data and help to identify how pediatric patients and their parents can be more involved in a shared decision-making process. Through the creation of a new decision aid (Option Grid), we hope to allow for a more clear line of communication at the bedside when helping patients and parents make these difficult treatment decisions.

Infections in children and adolescents with juvenile idiopathic arthritis and inflammatory bowel disease treated with tumor necrosis factor-α inhibitors: systematic review of the literature

Tumor necrosis factor alpha (TNF-α) inhibitors are increasingly administered to children and adolescents with juvenile idiopathic arthritis (JIA) and pediatric inflammatory bowel disease (pIBD). Adult studies indicate that TNF-α inhibitors lead to an increased risk of serious infections compared to other disease-modifying antirheumatic drugs. We report herein a systematic literature review detailing the epidemiology and types of infections reported in children with JIA and pIBD treated with TNF-α inhibitors. The most frequently reported infections were mild and characterized as viral in etiology. Severe bacterial and fungal infections also occurred, but were less common and possibly associated with intrinsic risk factors and concurrent immunosuppressive therapy. Few pediatric patients developed Mycobacterium tuberculosis, likely due to effective screening. There were 8 infectious fatalities in children treated with TNF-α inhibitors. Overall, although rare, serious infections occur in immunocompromised children and adolescents with JIA and pIBD receiving TNF-α inhibitors.

Pharmakologische Aspekte

Kortikosteroide waren die ersten Therapeutika zur Kontrolle von Abstoßungsreaktionen nach Transplantation. Sie sind seit Langem und immer noch wichtiger Bestandteil vieler immunsuppressiver Therapiekonzepte. Kortikosteroide besitzen zahlreiche antiinflammatorische und immunsuppressive Effekte. Sie beeinflussen über die Bindung spezifischer zytoplasmatischer Rezeptoren die Gentranskriptionsrate für zentrale, immunregulatorische Proteine wie Interleukin 1β (IL-1β), IL-6, Tumor-Nekrose-Faktor α (TNF-α) mit resultierender Suppression der Makrophagenfunktion und konsekutiver T-Zell-Aktivierung. Sie inhibieren auch die IL-2-Synthese, hemmen damit die T-Zell-Proliferation und reduzieren die IL- 2-Rezeptorbindungsfähigkeit. Andererseits stimulieren sie die Synthese des inhibierenden Zytokins „transforming growth factor β“ (TGF-β), was in einem „antiinflammatorisch“ geprägten T-Helfer-Zell-2-artigen Zytokinprofil resultiert. Über die Inhibition der Expression von interferonabhängigen Adhäsionsmolekülen (einschließlich MHC-Klasse-II-Moleküle) bewirken Kortikosteroide darüber hinaus die Alteration von Leukozytenverkehr und -transmigration sowie eine Induktion der Lymphozytenapoptose.

Safety and efficacy of adalimumab for moderate to severe Crohn's disease in children

BACKGROUND & AIMS

The IMAgINE 1 study (NCT00409682) evaluated the safety and efficacy of adalimumab double-blind maintenance dosing regimens following open-label induction for pediatric patients with moderate to severe Crohn's disease (CD).

METHODS

We studied 192 patients with Pediatric Crohn's Disease Activity Index (PCDAI) scores >30 for whom conventional treatment was unsuccessful. Patients received open-label induction therapy with subcutaneous adalimumab at weeks 0 and 2 (160 mg and 80 mg, or 80 mg and 40 mg, for body weight ≥40 kg or <40 kg). At week 4, 188 patients were assigned to groups based on achievement of clinical response (defined as decrease in PCDAI ≥15 points from baseline; 155/188 [82.4%]) and prior exposure to infliximab (82/188 [43.6%]). Groups were given double-blind maintenance therapy with adalimumab at high (40 mg or 20 mg for body weight ≥40 kg or <40 kg; n = 93) or low doses (20 mg or 10 mg for body weight ≥40 kg or <40 kg; n = 95) every other week for 48 weeks. Clinical remission (PCDAI ≤10) at week 26 (the primary end point) was compared between groups using the Cochran-Mantel-Haenszel test, adjusting for strata, with nonresponder imputation. Adverse events were monitored to evaluate safety.

RESULTS

A total of 152 of 188 patients (80.9%) completed all 26 weeks of the study. At week 26, 63 patients (33.5%) were in clinical remission, with no significant difference between high- and low-dose groups (36/93 [38.7%] vs 27/95 [28.4%]; P = .075). No new safety signals were detected.

CONCLUSIONS

Adalimumab induced and maintained clinical remission of children with CD, with a safety profile comparable to that of adult patients with CD. More children who received high compared with low dose were in remission at week 26, but the difference between dose groups was not statistically significant.

Antitumor necrosis factor treatment for pediatric inflammatory bowel disease

Infliximab, adalimumab, and certolizumab are monoclonal antibodies against tumor necrosis factor-α (TNFα), a proinflammatory cytokine with an increased expression in the inflamed tissues of inflammatory bowel disease (IBD) patients. Currently, infliximab is the only anti-TNF drug that has been approved for use in refractory pediatric Crohn's disease (CD). Nevertheless, adalimumab and certolizumab have been used off-label to treat refractory pediatric IBD. Over the past 10 years, anti-TNF treatment has been of great benefit to many pediatric IBD patients, but their use is not without risks (infections, autoimmune diseases, malignancies). Despite the growing experience with these drugs in children with IBD, optimal treatment strategies still need to be determined. The purpose of this review is to summarize the current knowledge on the use of anti-TNF drugs in pediatric IBD and to discuss the yet-unsolved issues.

The effects of anti-TNF-α treatment with adalimumab on growth in children with Crohn's disease (CD)

INTRODUCTION

Adalimumab is used to treat children with Crohn's disease (CD), but the effects of adalimumab on growth in CD have not been studied.

AIM

To study growth and disease activity over 12 months (6 months prior to (T-6), baseline (T0) and for 6 months following (T+6) adalimumab).

SUBJECTS AND METHODS

Growth and treatment details of 36 children (M: 22) who started adalimumab at a median (10th, 90th) age of 14.7 years (11.3, 16.8) were reviewed.

RESULTS

Of 36 cases, 28 (78%) went into remission. Overall 42% of children showed catch up growth, which was more likely in: (i) those who achieved remission (median change in height SDS (ΔHtSDS) increased from -0.2 (-0.9, 1.0) at T0 to 0.2 (-0.6, 1.6) at T+6, (p=0.007)), (ii) in those who were on immunosuppression ΔHtSDS increased from -0.2 (-0.9, 1.0) at T0 to 0.1 (-0.8, 1.3) at T+6, (p=0.03) and (iii) in those whose indication for using adalimumab therapy was an allergic reaction to infliximab, median ΔHtSDS increased significantly from -0.3 (-0.9, 1.0) at T0 to 0.3 (-0.5, 1.6) at T+6, (p=0.02). Median ΔHtSDS also increased from -0.4 (-0.8, 0.7) at T0 to 0.0 (-0.6, 1.6) at T+6, (p=0.04) in 15 children who were on prednisolone therapy when starting adalimumab.

CONCLUSION

Clinical response to adalimumab therapy is associated with an improvement in linear growth in a proportion of children with CD. Improved growth is more likely in patients entering remission and on immunosuppression but is not solely due to a steroid sparing effect.

Management of inflammatory bowel disease with infliximab and other anti-tumor necrosis factor alpha therapies

Inflammatory bowel disease (IBD), most commonly referring to Crohn's disease and ulcerative colitis, is a chronic and disabling condition with an increasing incidence in southern Europe. The etiology of IBD remains unknown, but the characteristic disproportionate inflammatory response in the gut may develop through various mechanisms at the cellular and subcellular level. Tumor necrosis factor (TNF) alpha is one crucial mediator of this abnormal immune response, and in recent years, biological therapies targeting TNFα have significantly improved the management of IBD refractory to conventional therapies. Infliximab is the best studied anti-TNFα agent, and is currently approved in the European Union for adults and children with Crohn's disease and adults with ulcerative colitis; adalimumab is indicated for Crohn's disease in adults but not children, while certolizumab was not approved in the European Union for Crohn's disease. Infliximab has confirmed efficacy in adults with Crohn's disease (including fistulizing disease) and ulcerative colitis, with benefits observed in both clinical remission and mucosal healing, it is similarly effective in children with Crohn's disease. Evidence suggests that early treatment with infliximab may improve the natural course of the disease. Adalimumab showed efficacy in adults with Crohn's disease and more limited data suggest efficacy in children with Crohn's disease. Although certolizumab pegol has also shown promising data in adults with Crohn's disease, data in children are lacking. Anti-TNFα agents are generally well tolerated, although careful monitoring for adverse events such as infections, infusion reactions, lymphomas and demyelinating diseases is warranted. A definitive causal relationship between anti-TNFα agents and various adverse events is difficult to establish, as the underlying disease and concomitant immunosuppression also predispose patients to such events. Infliximab has not been associated with an increased incidence of serious events, and adalimumab and certolizumab are also generally well tolerated in clinical trials. Both adalimumab and certolizumab pegol are associated with lower levels of drug antibodies compared with infliximab. Reactivation of latent tuberculosis is a potential risk with any anti-TNFα agent, and identification and treatment is required before initiating therapy. Although causal relationships are difficult to establish, caution is advised with anti-TNFα compounds in patients developing neurological symptoms suggestive of demyelinating disease, or in those at high risk of malignancy. Infliximab is also generally well tolerated in children; however, data are scarce for the other compounds. No increased risks associated with pregnancy have been observed for infliximab or adalimumab, but caution in pregnancy and during breast-feeding is currently advocated. In terms of future research, more long-term data are needed for both certolizumab pegol in Crohn's disease and adalimumab in ulcerative colitis. More research on the benefits of early biological treatment on disease progression is needed. In summary, the anti-TNFα inhibitors represent a momentous advance in the treatment of Crohn's disease and ulcerative colitis refractory to conventional treatments. They offer significant benefits in quality of life and mucosal healing, and may have the potential to change the evolution of the disease when given early.

Loss of response and need for adalimumab dose intensification in Crohn's disease: a systematic review

The objective of this study was to review loss of response and need for adalimumab dose intensification in adult and pediatric patients with Crohn's disease. Studies were identified through the electronic databases of MEDLINE and the annual meetings of Digestive Disease Week, of the United European Gastroenterology Week, and of the American College of Gastroenterology and the European Crohn's and Colitis Organization meetings. Studies evaluating loss of efficacy and/or need for dose intensification were included. Thirty-nine studies were included. The mean percentage of loss of response to adalimumab among primary responders was 18.2% and the annual risk was 20.3% per patient-year. The mean percentage of patients who required dose intensification among primary responders to adalimumab was 37% and the annual risk was 24.8% per patient-year. When considering initial responders and patients with primary non-response, the mean percentage of patients who needed an adalimumab dose escalation was 21.4% and the annual risk was 24.4% per patient-year. Pooled analysis showed that dose escalation permitted response to be regained in 71.4% and remission in 39.9% of patients. Predictors for loss of response or dose escalation were male gender, current/former smoker status, family history of inflammatory bowel disease, isolated colonic disease, extra-intestinal manifestations, 80/40  mg induction therapy, longer disease duration, greater baseline Crohn's Disease Activity Index, concomitant corticosteroid use, no deep remission at week 12, low serum trough concentrations of adalimumab, previous infliximab non-response and being previously treated with an anti-tumor necrosis factor agent. Overall, around one fifth of adult patients require dose intensification and experience a loss of response after initiation of adalimumab therapy. Adalimumab dose escalation permits response to be regained in the majority of patients.

A British Society of Paediatric Gastroenterology, Hepatology and Nutrition survey of the effectiveness and safety of adalimumab in children with inflammatory bowel disease

BACKGROUND

Adalimumab is efficacious therapy for adults with Crohn's disease (CD).

AIM

To summarise the United Kingdom and Republic of Ireland paediatric adalimumab experience.

METHODS

British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) members with Inflammatory Bowel Disease (IBD) patients <18 years old commencing adalimumab with at least 4 weeks follow-up. Patient demographics and details of treatment were then collected. Response and remission was assessed using the Paediatric Crohn's Disease Activity Index (PCDAI)/Physicians Global Assessment (PGA).

RESULTS

Seventy-two patients [70 CD, 1 ulcerative colitis (UC), 1 IBD unclassified (IBDU)] from 19 paediatric-centres received adalimumab at a median age of 14.8 (IQR 3.1, range 6.1-17.8) years; 66/70 CD (94%) had previously received infliximab. A dose of 80 mg then 40 mg was used for induction in 41(59%) and 40 mg fortnightly for maintenance in 61 (90%). Remission rates were 24%, 58% and 41% at 1, 6 and 12 months, respectively. Overall 43 (61%) went into remission at some point, with 24 (35%) requiring escalation of therapy. Remission rates were higher in those on concomitant immunosuppression cf. those not on immunosuppression [34/46 (74%) vs. 9/24 (37%), respectively, (χ(2) 8.8, P=0.003)]. There were 15 adverse events (21%) including four (6%) serious adverse events with two sepsis related deaths in patients who were also on immunosuppression and home parenteral nutrition (3% mortality rate).

CONCLUSIONS

Adalimumab is useful in treatment of refractory paediatric patients with a remission rate of 61%. This treatment benefit should be balanced against side effects, including in this study a 3% mortality rate.

Recalcitrant pustular psoriasis successfully treated with adalimumab

We report a 13-year-old girl with severe pustular psoriasis who had an excellent response to treatment with adalimumab after failure with methotrexate, acitretin, cyclosporin, phototherapy, and biologic drugs including etanercept and infliximab.

The London Position Statement of the World Congress of Gastroenterology on Biological Therapy for IBD with the European Crohn's and Colitis Organisation: pregnancy and pediatrics

Women with inflammatory bowel disease (IBD) have similar rates of fertility to the general population, but have an increased rate of adverse pregnancy outcomes compared with the general population, which may be worsened by disease activity. Infertility is increased in those undergoing ileal pouch-anal anastomosis. Anti-tumor necrosis factor therapy in pregnancy is considered to be low risk and compatible with use during conception in men and women and during pregnancy in at least the first two trimesters. Infliximab (IFX) and certolizumab pegol are also compatible with breastfeeding, but safety data for adalimumab (ADA) are awaited. The safety of natalizumab during pregnancy is unknown. For children with Crohn's disease (CD), IFX is effective at inducing and maintaining remission. Episodic therapy is not as effective as scheduled infusions. Disease duration in children does not appear to affect the efficacy of IFX. IFX promotes growth in prepubertal and early pubertal Crohn's patients. It is also effective for the treatment of extraintestinal manifestations. ADA is effective for children with active CD and for maintaining remission, even if they have lost response to IFX, although there are fewer data. Vaccination of infants exposed to biological therapy in utero should be given at standard schedules during the first 6 months of life, except for live-virus vaccines such as rotavirus. Inactivated vaccines may be safely administered to children with IBD, even when immunocompromised.

Long-term efficacy of adalimumab in paediatric Crohn's disease patients naïve to other anti-TNF therapies

INTRODUCTION

Adalimumab is a fully-humanized anti-TNF a antibody that has showed its efficacy in Crohn's disease (CD) adult patients. Its less immunogenic composition seems to be an advantage compared to previous anti-TNF α, mainly infliximab. Good response to adalimumab has been reported in patients naïve to infliximab, in those in whom infliximab has shown no efficacy and in those intolerant or who have lost previous response to it. Adalimumab has shown also its efficacy as a second-line anti-TNF α in small series of paediatric CD but data regarding its use in children naïve to infliximab are scarce.

AIM

To report our experience with adalimumab as first line anti-TNF α treatment in paediatric CD.

PATIENTS AND METHODS

Four CD paediatric patients (2 boys) previously naïve to infliximab have received adalimumab. Mean age at diagnosis: 13 years, 4 months. Adalimumab was initiated in our patients soon after diagnosis (mean time from diagnosis: 8.5 months, range: 1 month 15 days-14 months) at decreasing loading doses (160 mg and 80 mg two weeks after) and then 40 mg subsequently every two weeks.

RESULTS

The four patients entered in remission after the first dose of adalimumab (mean previous PCDAI: 35, mean PCDAI after first dose: 3.6). No adverse effects were registered. Azathioprine was stopped after 4 months of combination therapy, without loss of efficacy or adverse reactions attributable to immunogenicity. All the 4 patients have remained in remission on adalimumab monotherapy for a mean follow-up of 17 months (range 9-20 months).

CONCLUSION

Adalimumab has shown its efficacy in our paediatric CD patients naïve to other anti-TNF α drugs. Early introduction of anti-TNF α antibodies in these patients could help to a better control of the disease. Its less immunogenicity and the possibility of a home-based administration are advantages when compared to other parenteral anti-TNF treatments. Change to monotherapy after prior successful combination therapy with azathioprine and adalimumab is a safe strategy that can help to minimize possible risks of intensive immunomodulation.

Systematic review: steroid withdrawal in anti-TNF-treated patients with inflammatory bowel disease

BACKGROUND

The increasing awareness of increased risk for opportunistic infections when combining several immunosuppressant drugs led to new treatment goals for inflammatory bowel disease including limited use of steroids.

AIM

To conduct a systematic review to establish figures for steroid withdrawal in anti-TNF treated inflammatory bowel disease-patients.

METHODS

Medline was searched using the search-terms Ulcerative Colitis (UC) [Mesh], Crohn Disease (CD) [Mesh], IBD [Mesh], crohn, colitis, IBD and steroid sparing, all combined with infliximab and adalimumab. We selected English-language publications that addressed the effect of anti-TNF on steroid withdrawal. Studies had to assess patients with luminal CD or UC. Numbers of patients who were able to withdraw steroids were calculated.

RESULTS

Six studies could be included; five reporting on infliximab and one on adalimumab. Studies were heterogeneously designed. Overall, in the adult population, up to 38% of the patients were able to withdraw corticosteroids during infliximab therapy. In the paediatric population, up to 75% of the patients were able to withdraw corticosteroids during infliximab therapy.

CONCLUSIONS

Although a consensus on the definition of steroid-sparing is lacking, approximately two-thirds of the inflammatory bowel disease-patients are unable to withdraw corticosteroid treatment during anti-TNF therapy.

Inflammatory bowel disease in children: current trends

Once considered rare in the East, inflammatory bowel disease (IBD) is now recognized to be an emerging entity in that region. East or West, the clinical features of and treatment options for IBD are the same, but it is possible that the exact pathogeneses or the initiating events differ. In this review, existing knowledge of IBD and new discoveries in the epidemiology, genetics and treatment of IBD are discussed in detail. The diagnosis and management of IBD in children has changed dramatically over the last decade, mainly due to increased awareness, the availability of newer diagnostic modalities such as MRI and video capsule endoscopy, and newer, more powerful treatments such as biologics. It is hoped that the combination of innovative research and advances in drug discoveries will change the natural history of IBD and make a major difference in children who are suffering from this unfortunate lifelong chronic inflammatory disorder.

Survey on the use of adalimumab as maintenance therapy in Crohn's disease in England and Ireland

INTRODUCTION

Adalimumab is effective in inducing and maintaining response/remission in patients with Crohn's disease either naive to biological therapies or after secondary failure of infliximab.

AIM

To present the first 'real-life' survey data from England and Ireland on the use of adalimumab.

METHOD

A retrospective audit conducted through a web-based questionnaire in England/Ireland.

RESULTS

We analysed data on 61 patients (35 female, 26 male) with a median age of 33 years (range 17-71 years) and an average follow-up of 8 months. The maximal maintenance dose was 40 mg every other week in 84% of patients, 40 mg weekly in 13% and 80 mg weekly in 3%. Maintenance adalimumab achieved remission in 57% of patients. The ongoing response rate was 83.6%. An additional 8% had a secondary loss of response after an average of 8.4 months (range 2-17). Adverse effects were observed in 23% of patients: of which there was local pain in 29%, infection in 36%, headaches in 14%, leucopenia (on azathioprine) in 7%, a painful rash in 7% and serum-sickness-type reaction in 7%. Adverse events led to discontinuation in two patients.

CONCLUSION

This English/Irish audit shows an acceptable response/remission and safety profile of adalimumab in the treatment of Crohn's disease. In contrast to earlier data from Scotland, dose escalation was only observed in 16% of patients. The majority of responders were steroid-free at follow-up.

Retrospective Evaluation of the Safety and Effect of Adalimumab Therapy (RESEAT) in pediatric Crohn's disease

OBJECTIVES

Adalimumab, an anti-tumor necrosis factor immunoglobulin-1 antibody, is increasingly being reported as a potential treatment option for children with moderate-to-severe Crohn's disease (CD). The aim of this study was to characterize common indications, safety, tolerability, and clinical response to adalimumab in pediatric CD in a large, multicenter, patient cohort.

METHODS

Data were obtained using a retrospective, uncontrolled chart review at 12 sites of the Pediatric Inflammatory Bowel Disease Collaborative Research Group. Clinical, laboratory, and demographic data were obtained for CD patients who received at least one dose of adalimumab. Indication for adalimumab, concomitant medications, and clinical outcome at 3, 6, and 12 months for each patient were recorded using physician global assessment (PGA) and Pediatric CD Activity Index scores. Serious adverse events were identified.

RESULTS

A total of 115 patients (54% female) received at least one dose of adalimumab. The mean age at the diagnosis of CD was 11.1+/-3.1 years, with the first adalimumab dose administered at 4.7+/-2.8 years after diagnosis. The most common dosing frequency was every other week with induction doses of 160/80 mg in 19%, 80/40 mg in 44%, and 40/40 mg in 15% of patients. Maintenance dosing was 40 mg every other week in 88% of patients. Mean follow-up after initial adalimumab dose was 10+/-8.6 months. Infliximab treatment preceded adalimumab in 95% of patients, with a mean of 12 infliximab infusions (range: 1-44). Infliximab discontinuation was due to loss of response (47%), infusion reaction or infliximab intolerance (45%), or preference for a subcutaneous medication (9%). Concomitant medications at the commencement of adalimumab were corticosteroids (38%), azathioprine/6-mercaptopurine (41%), and methotrexate (23%). Clinical response measured by PGA at 3, 6, and 12 months was 65, 71, and 70%, respectively, with steroid-free remission at 3, 6, and 12 months of 22, 33, and 42%, respectively. There were no malignancies, serious infections, or deaths in the study subjects.

CONCLUSIONS

Adalimumab was a well-tolerated and effective rescue therapy for moderate-to-severe pediatric CD patients previously treated with infliximab. Adalimumab demonstrated a steroid-sparing effect, and >70% of patients achieved rapid response that was sustained through 12 months.

[Adalimumab treatment in infliximab-resistant pediatric patient with Crohn's disease]

Treatment with the chimeric monoclonal antibody (infliximab) is highly effective in refractory and fistulising Crohn's disease, nevertheless, infliximab resistance may occur. Authors report a 12-year-old boy with infliximab refractory luminal Crohn's disease including 3 active perianal fistulas. The patient was treated successfully with adalimumab, a fully human anti-tumor necrosis factor alpha monoclonal antibody. After 10 weeks of therapy, the previously high activity index returned to normal and the fistulas were closed. Quality of life using validated questionnaire improved significantly also. Adalimumab might be a suitable therapy even in pediatric Crohn's disease patients with infliximab resistance.

Efficacy of adalimumab in moderate-to-severe pediatric Crohn's disease

OBJECTIVES

The use of tumor necrosis factor-alpha (TNF-alpha) antagonists has changed the therapeutic strategy for Crohn's disease (CD). Adalimumab (ADA), a fully human anti-TNF-alpha monoclonal antibody, is an effective therapy for patients with CD, both naive patients and those intolerant or refractory to Infliximab (IFX), a chimeric anti-TNF-alpha agent. However, the use of ADA is rarely reported in pediatric CD. We performed an open prospective evaluation of short- and long-term efficacy and safety of ADA in children with moderate-to-severe CD.

METHODS

A total of 23 pediatric CD patients (9 naive and 14 intolerant or unresponsive to IFX) received ADA subcutaneously as a loading schedule at weeks 0 and 2, and at every other week (eow) during a 48-week maintenance phase. Loading and maintenance doses were 160/80 and 80 mg eow in 13 cases, 120/80 and 80 mg eow in 2, and 80/40 and 40 mg eow in 8 cases. The primary efficacy outcomes were clinical remission and response at different scheduled visits along the maintenance phase. At baseline, 13 patients also received immunomodulators (IMs).

RESULTS

At weeks 2, 4, 12, 24, and 48, remission rates were 36.3, 60.8, 30.5, 50, and 65.2%, respectively, whereas response rates were 87, 88, 70, 86, and 91%, respectively. Four patients at week 24 and 2 at week 48 received IMs; the mean daily corticosteroid dose, disease activity index, C-reactive protein level, and erythrocyte sedimentation rate decreased significantly throughout the trial. No serious adverse events were recorded.

CONCLUSIONS

ADA can be an effective and safe biological agent for inducing and maintaining remission in children with moderate-to-severe CD, even in those with previous IFX therapy.

Use of biologic agents in pediatric inflammatory bowel disease

PURPOSE OF REVIEW

Owing to its aggressive clinical course and associated immunologic abnormalities, pediatric inflammatory bowel disease (IBD) is increasingly managed with immunomodulators and biologic agents. Clinical experience with therapy targeted against tumor necrosis factor-alpha has raised important questions about these agents, which will be addressed in this review.

RECENT FINDINGS

Pediatric IBD is increasingly appreciated to have a variety of recognized clinical phenotypes that are associated with particular genotypes and serologic responses. These observations may ultimately allow individualized therapy that could change the natural history of pediatric IBD and reverse its severe metabolic and growth effects. Several new studies suggest that antitumor necrosis factor therapy could be an important part of this therapeutic vista. In addition to shedding light on who could best benefit from such agents, optimization of such therapy and its safety have been active areas of recent research.

SUMMARY

Biologic therapy for pediatric IBD is an increasingly employed strategy. The aggressive nature of the disease and its consequent metabolic effects make this an attractive option for many patients. Recent research is helping guide the clinician to identify who could best benefit from such therapy while also exploring its safety and ideal dosing strategy.

Análise de custo-minimização entre o Infliximabe (IFX) e o Adalimumabe (ADA) no tratamento da doença de Crohn (DC)

INTRODUÇÃO: há uma preocupação crescente com os custos da terapia biológica no tratamento da DC. O objetivo deste estudo foi simular o custo-minimização do tratamento contínuo com o IFX e com o ADA em portadores de DC, num período de 1 ano, em variadas faixas de peso. MÉTODO: estudo farmacoeconômico de custo-minimização na simulação de tratamento com agentes biológicos de pacientes portadores de DC, com pesos diferentes. Os custos foram baseados no preço dos dois medicamentos isoladamente (IFX E ADA). RESULTADOS: o custo do tratamento com IFX (sistema público) foi de R$ 29.411,12 (entre 20 e 40 kg), R$ 44.116,68 (entre 41 e 60 kg), R$ 58.822,24 (entre 61 e 80 kg) e R$ 73.527,80 (entre 81 e 100 kg). O custo com ADA foi de R$ 52.045,16, independentemente do peso. A análise do sistema privado e situações de perda de resposta encontram-se descritas no artigo. CONCLUSÕES: houve menores custos com o uso do IFX abaixo de 60 kg, e com o ADA acima deste peso. Em simulação de perda de resposta ao IFX, houve menores custos absolutos com a troca para ADA do que aumento de dose do IFX, entre 40 e 100 kg.