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Abedalweli R, Nguyen M, Deodhar A. Combination biologics or targeted synthetic disease-modifying anti-rheumatic drugs in the treatment of spondyloarthritis: a systematic literature review. Expert Rev Clin Immunol 2024:1-9. [PMID: 38512065 DOI: 10.1080/1744666x.2024.2327589] [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: 10/01/2023] [Accepted: 02/23/2024] [Indexed: 03/22/2024]
Abstract
INTRODUCTION The advent of biologic and targeted synthetic disease-modifying anti-rheumatic drugs (b/tsDMARDs) have transformed the management of immune-mediated rheumatic diseases, including spondylarthritis (SpA). However, the data about combining b/ts DMARDs in the treatment of SpA are scarce. The study objectives were to assess the efficacy and safety of combination b/tsDMARD in SpA. METHODS We conducted systematic literature review (PubMed and Medline) with two independent reviewers, one adjudicator, exploring the efficacy and safety of combination b/tsDMARDs in the treatment of SpA. Inclusion criteria were studies published in last 20 years, English language, interventions included use of two b/tsDMARDs, and minimal three-month follow-up. RESULTS Out of 1936 initial hits, 28 manuscripts fulfilled the inclusion criteria. Two were randomized controlled trials, and the remaining were retrospective cohort studies or case series. Combination of apremilast with bDMARD, or TNF inhibitor plus IL12/23 inhibitor were the commonest and reported good efficacy with no increased safety signal. CONCLUSIONS There is not enough data to fully evaluate efficacy and safety of combination b/tsDMARDs in SpA treatment. Limited information shows apremilast plus bDMARD, or TNF inhibitor plus IL12/23 inhibitor combination to be efficacious and safe. Randomized controlled trials and larger cohort with a longer follow-up are required.
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Affiliation(s)
- Rand Abedalweli
- Department of Medicine, Oregon Health & Science University/Hillsboro Medical Center, Portland, OR, USA
| | - Michelle Nguyen
- Department of Medicine, Providence St. Vincent Hospital, Portland, OR, USA
| | - Atul Deodhar
- Division of Arthritis and Rheumatic Diseases, Oregon Health & Science University, Portland, OR, USA
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Spencer EA, Bergstein S, Dolinger M, Pittman N, Kellar A, Dunkin D, Dubinsky MC. Single-center Experience With Upadacitinib for Adolescents With Refractory Inflammatory Bowel Disease. Inflamm Bowel Dis 2023:izad300. [PMID: 38134405 DOI: 10.1093/ibd/izad300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Upadacitinib (UPA) is a novel selective JAK inhibitor approved for adults with ulcerative colitis (UC) and with positive phase 3 data for Crohn's disease (CD). Pediatric off-label use is common due to delays in pediatric approvals; real-world data on UPA are needed to understand the safety and effectiveness in pediatric IBD. METHODS This is a single-center retrospective case series study of adolescents (12-17 years) with inflammatory bowel disease IBD on UPA. The primary outcome was postinduction steroid-free clinical remission (SF-CR) defined as Pediatric UC Activity Index (PUCAI) or Pediatric CD Activity Index (PCDAI) ≤10. Secondary outcomes include postinduction clinical response (decrease ≥12.5 in PUCAI/PCDAI), postinduction C-reactive protein (CRP) normalization, 6-month SF-CR, and intestinal ultrasound response and remission. Adverse events were recorded through last follow-up. RESULTS Twenty patients (9 CD, 10 UC, 1 IBD-U; 55% female; median age 15 years, 90% ≥2 biologics) were treated with UPA for ≥12 weeks (median 51 [43-63] weeks). Upadacitinib was used as monotherapy in 55% and as combination with ustekinumab and vedolizumab in 35% and 10%, respectively. Week 12 SF-CR was achieved in 75% (15/20) and 80% (16/20) with CRP normalization. About 3/4 (14/19) achieved SF-CR at 6 months. Adverse event occurred in 2 patients (10%): Cytomegalovirus colitis requiring hospitalization and hyperlipidemia requiring no treatment. In the 75% with ultrasound monitoring, response and remission were achieved in 77% and 60%, respectively. CONCLUSION While awaiting pediatric registration trials, our data suggest that UPA is effective in inducing and maintaining SF-CR in adolescents with highly-refractory IBD with an acceptable safety profile.
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Affiliation(s)
- Elizabeth A Spencer
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics Mount Sinai, Icahn School of Medicine, 17 E. 102nd Street, Fifth Floor, New York, NY, 10029, USA
| | - Suzannah Bergstein
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics Mount Sinai, Icahn School of Medicine, 17 E. 102nd Street, Fifth Floor, New York, NY, 10029, USA
| | - Michael Dolinger
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics Mount Sinai, Icahn School of Medicine, 17 E. 102nd Street, Fifth Floor, New York, NY, 10029, USA
| | - Nanci Pittman
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics Mount Sinai, Icahn School of Medicine, 17 E. 102nd Street, Fifth Floor, New York, NY, 10029, USA
| | - Amelia Kellar
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics Mount Sinai, Icahn School of Medicine, 17 E. 102nd Street, Fifth Floor, New York, NY, 10029, USA
| | - David Dunkin
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics Mount Sinai, Icahn School of Medicine, 17 E. 102nd Street, Fifth Floor, New York, NY, 10029, USA
| | - Marla C Dubinsky
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics Mount Sinai, Icahn School of Medicine, 17 E. 102nd Street, Fifth Floor, New York, NY, 10029, USA
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Valero-Martínez C, Urgelles JF, Sallés M, Joven-Ibáñez BE, de Juanes A, Ramírez J, Juanola X, Almodóvar R, Laiz A, Moreno M, Pujol M, Beltrán E, Pinto-Tasende JA, Crespí L, Sala-Icardo L, Castañeda S, García-Vicuña R. Dual targeted therapy in patients with psoriatic arthritis and spondyloarthritis: a real-world multicenter experience from Spain. Front Immunol 2023; 14:1283251. [PMID: 37936691 PMCID: PMC10627177 DOI: 10.3389/fimmu.2023.1283251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 10/10/2023] [Indexed: 11/09/2023] Open
Abstract
Dual targeted therapy (DTT) has emerged as a promising approach in patients with refractory spondyloarthritis (SpA) or psoriatic arthritis (PsA) and extra-musculoskeletal manifestations of both diseases, but its effectiveness/safety ratio still remains unclear. This is a retrospective, real-world multicenter study in refractory SpA and PsA patients with simultaneous use of two biological or synthetic targeted agents. Effectiveness was assessed using Ankylosing Spondylitis Disease Activity Score with C-reactive protein (ASDAS-CRP) and Disease Activity in Psoriatic Arthritis (DAPSA) Score. We identified 39 different DTT combinations in 36 patients (22 SpA; 14 PsA), 25 of them with concomitant inflammatory bowel disease. The most commonly used combinations were TNF inhibitor plus antagonist of the IL12/23 pathway, followed by TNF inhibitor plus IL-17 antagonist. During a median exposure of 14.86 months (IQR 8-20.2), DTT retention rate was 69.4% (n=25/36; 19 SpA, 6 PsA). Major clinical improvement (change in ASDAS-CRP > 2 or improvement > 85% in DAPSA) was achieved in 69.4% of patients (n=25/36 therapeutical combinations; 17/21 SpA, 8/15 PsA), with a 58.3% (n=21/36 combinations; 15/20 SpA, 6/13 PsA) low-activity/remission rate. Of the patients who were receiving glucocorticoids, 55% managed to withdraw them during follow-up. Interestingly, only four serious adverse events in three patients were observed, leading to DTT discontinuation.
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Affiliation(s)
| | | | - Meritxell Sallés
- Rheumatology Unit, Althaia Xarxa Assistencial Universitària, Manresa, Spain
| | | | | | - Julio Ramírez
- Rheumatology Unit, Hospital Clinic, Barcelona, Spain
| | - Xavier Juanola
- Rheumatology Unit, Hospital U. Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Raquel Almodóvar
- Rheumatology Unit, Hospital U. Fundación Alcorcón, Madrid, Spain
| | - Ana Laiz
- Rheumatology Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Mireia Moreno
- Rheumatology Unit, Hospital U. Parc Taulí, I3PT (UAB), Sabadell, Spain
| | - Manel Pujol
- Rheumatology Unit, Hospital U, Mútua Terrassa, Barcelona, Spain
| | - Emma Beltrán
- Rheumatology Unit, Hospital del Mar, Barcelona, Spain
| | | | - Laura Crespí
- Rheumatology Unit, Hospital de Manacor, Manacor, Spain
| | | | - Santos Castañeda
- Rheumatology Unit, Hospital U. de La Princesa, IIS-Princesa, Madrid, Spain
- Cátedra Universidad Autónoma de Madrid UAM-Roche, enfermedad pulmonar intersticial difusa (EPID)-Future, Department of Medicine, Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Rosario García-Vicuña
- Rheumatology Unit, Hospital U. de La Princesa, IIS-Princesa, Madrid, Spain
- Department of Medicine, Universidad Autónoma de Madrid (UAM), Madrid, Spain
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Mutlu MY, Tascilar K, Schett G. Rationale, current state and opportunities in combining biologic disease modifying antirheumatic drugs in rheumatoid and psoriatic arthritis. Joint Bone Spine 2023; 90:105578. [PMID: 37076093 DOI: 10.1016/j.jbspin.2023.105578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 03/23/2023] [Accepted: 03/29/2023] [Indexed: 04/21/2023]
Abstract
The advent of biologic disease modifying antirheumatic drugs (bDMARDs) has considerably improved patient outcomes in inflammatory arthritis. However, not all patients reach the state of remission, as disease can be resistant even to single cytokine inhibition by bDMARDs. Simultaneous or sequential inhibition of multiple cytokines may be considered in situations where disease control is not adequate under singular inhibition of cytokines. Although there have been some disappointing experiences in the past with combination of bDMARDs, the ongoing improvement of our understanding about inflammatory pathways and the overall better safety understanding of bDMARDs seem to make new biologic treatment combinations possible. This review covers the rationale and current evidence for bDMARDs combination in inflammatory arthritis.
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Affiliation(s)
- Melek Yalcin Mutlu
- Department of Internal Medicine 3 - Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany; Deutsches Zentrum für Immuntherapie (DZI), Friedrich-Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Koray Tascilar
- Department of Internal Medicine 3 - Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany; Deutsches Zentrum für Immuntherapie (DZI), Friedrich-Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Georg Schett
- Department of Internal Medicine 3 - Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany; Deutsches Zentrum für Immuntherapie (DZI), Friedrich-Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany.
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