1
|
Chanchlani N, Lin S, Bewshea C, Hamilton B, Thomas A, Smith R, Roberts C, Bishara M, Nice R, Lees CW, Sebastian S, Irving PM, Russell RK, McDonald TJ, Goodhand JR, Ahmad T, Kennedy NA. Mechanisms and management of loss of response to anti-TNF therapy for patients with Crohn's disease: 3-year data from the prospective, multicentre PANTS cohort study. Lancet Gastroenterol Hepatol 2024; 9:521-538. [PMID: 38640937 DOI: 10.1016/s2468-1253(24)00044-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 01/31/2024] [Accepted: 02/09/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND We sought to report the effectiveness of infliximab and adalimumab over the first 3 years of treatment and to define the factors that predict anti-TNF treatment failure and the strategies that prevent or mitigate loss of response. METHODS Personalised Anti-TNF therapy in Crohn's disease (PANTS) is a UK-wide, multicentre, prospective observational cohort study reporting the rates of effectiveness of infliximab and adalimumab in anti-TNF-naive patients with active luminal Crohn's disease aged 6 years and older. At the end of the first year, sites were invited to enrol participants still receiving study drug into the 2-year PANTS-extension study. We estimated rates of remission across the whole cohort at the end of years 1, 2, and 3 of the study using a modified survival technique with permutation testing. Multivariable regression and survival analyses were used to identify factors associated with loss of response in patients who had initially responded to anti-TNF therapy and with immunogenicity. Loss of response was defined in patients who initially responded to anti-TNF therapy at the end of induction and who subsequently developed symptomatic activity that warranted an escalation of steroid, immunomodulatory, or anti-TNF therapy, resectional surgery, or exit from study due to treatment failure. This study was registered with ClinicalTrials.gov, NCT03088449, and is now complete. FINDINGS Between March 19, 2014, and Sept 21, 2017, 389 (41%) of 955 patients treated with infliximab and 209 (32%) of 655 treated with adalimumab in the PANTS study entered the PANTS-extension study (median age 32·5 years [IQR 22·1-46·8], 307 [51%] of 598 were female, and 291 [49%] were male). The estimated proportion of patients in remission at the end of years 1, 2, and 3 were, for infliximab 40·2% (95% CI 36·7-43·7), 34·4% (29·9-39·0), and 34·7% (29·8-39·5), and for adalimumab 35·9% (95% CI 31·2-40·5), 32·9% (26·8-39·2), and 28·9% (21·9-36·3), respectively. Optimal drug concentrations at week 14 to predict remission at any later timepoints were 6·1-10·0 mg/L for infliximab and 10·1-12·0 mg/L for adalimumab. After excluding patients who had primary non-response, the estimated proportions of patients who had loss of response by years 1, 2, and 3 were, for infliximab 34·4% (95% CI 30·4-38·2), 54·5% (49·4-59·0), and 60·0% (54·1-65·2), and for adalimumab 32·1% (26·7-37·1), 47·2% (40·2-53·4), and 68·4% (50·9-79·7), respectively. In multivariable analysis, loss of response at year 2 and 3 for patients treated with infliximab and adalimumab was predicted by low anti-TNF drug concentrations at week 14 (infliximab: hazard ratio [HR] for each ten-fold increase in drug concentration 0·45 [95% CI 0·30-0·67], adalimumab: 0·39 [0·22-0·70]). For patients treated with infliximab, loss of response was also associated with female sex (vs male sex; HR 1·47 [95% CI 1·11-1·95]), obesity (vs not obese 1·62 [1·08-2·42]), baseline white cell count (1·06 [1·02-1·11) per 1 × 109 increase in cells per L), and thiopurine dose quartile. Among patients treated with adalimumab, carriage of the HLA-DQA1*05 risk variant was associated with loss of response (HR 1·95 [95% CI 1·17-3·25]). By the end of year 3, the estimated proportion of patients who developed anti-drug antibodies associated with undetectable drug concentrations was 44·0% (95% CI 38·1-49·4) among patients treated with infliximab and 20·3% (13·8-26·2) among those treated with adalimumab. The development of anti-drug antibodies associated with undetectable drug concentrations was significantly associated with treatment without concomitant immunomodulator use for both groups (HR for immunomodulator use: infliximab 0·40 [95% CI 0·31-0·52], adalimumab 0·42 [95% CI 0·24-0·75]), and with carriage of HLA-DQA1*05 risk variant for infliximab (HR for carriage of risk variant: infliximab 1·46 [1·13-1·88]) but not for adalimumab (HR 1·60 [0·92-2·77]). Concomitant use of an immunomodulator before or on the day of starting infliximab was associated with increased time without the development of anti-drug antibodies associated with undetectable drug concentrations compared with use of infliximab alone (HR 2·87 [95% CI 2·20-3·74]) or introduction of an immunomodulator after anti-TNF initiation (1·70 [1·11-2·59]). In years 2 and 3, 16 (4%) of 389 patients treated with infliximab and 11 (5%) of 209 treated with adalimumab had adverse events leading to treatment withdrawal. Nine (2%) patients treated with infliximab and two (1%) of those treated with adalimumab had serious infections in years 2 and 3. INTERPRETATION Only around a third of patients with active luminal Crohn's disease treated with an anti-TNF drug were in remission at the end of 3 years of treatment. Low drug concentrations at the end of the induction period predict loss of response by year 3 of treatment, suggesting higher drug concentrations during the first year of treatment, particularly during induction, might lead to better long-term outcomes. Anti-drug antibodies associated with undetectable drug concentrations of infliximab, but not adalimumab, can be predicted by carriage of HLA-DQA1*05 and mitigated by concomitant immunomodulator use for both drugs. FUNDING Guts UK, Crohn's and Colitis UK, Cure Crohn's Colitis, AbbVie, Merck Sharp and Dohme, Napp Pharmaceuticals, Pfizer, and Celltrion Healthcare.
Collapse
Affiliation(s)
- Neil Chanchlani
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Simeng Lin
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Claire Bewshea
- Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Benjamin Hamilton
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Amanda Thomas
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Rebecca Smith
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Christopher Roberts
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Maria Bishara
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Rachel Nice
- Department of Blood Science, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Charlie W Lees
- Department of Gastroenterology, Edinburgh IBD Unit, Western General Hospital, NHS Lothian, Edinburgh, UK; Institute of Genetic and Cancer, University of Edinburgh, Edinburgh, UK
| | - Shaji Sebastian
- Gastroenterology and Hepatology, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK; Hull York Medical School, University of Hull, Hull, UK
| | - Peter M Irving
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK; School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children & Young People, Edinburgh, UK; Child Life and Health, University of Edinburgh, Royal Hospital for Children & Young People, Edinburgh, UK
| | - Timothy J McDonald
- Department of Blood Science, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - James R Goodhand
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Tariq Ahmad
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Nicholas A Kennedy
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK.
| |
Collapse
|
2
|
Rodríguez-Moranta F, Argüelles-Arias F, Hinojosa Del Val J, Iborra Colomino M, Martín-Arranz MD, Menchén Viso L, Muñoz Núñez F, Ricart Gómez E, Sánchez-Hernández JG, Valdés-Delgado T, Guardiola Capón J, Barreiro-de Acosta M, Mañosa Ciria M, Zabana Abdo Y, Gutiérrez Casbas A. Therapeutic drug monitoring in inflammatory bowel diseases. Position statement of the Spanish Working Group on Crohn's Disease and Ulcerative Colitis. Gastroenterol Hepatol 2024; 47:522-552. [PMID: 38311005 DOI: 10.1016/j.gastrohep.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/31/2023] [Accepted: 01/18/2024] [Indexed: 02/06/2024]
Abstract
The treatment of inflammatory bowel disease has undergone a significant transformation following the introduction of biologic drugs. Thanks to these drugs, treatment goals have evolved from clinical response and remission to more ambitious objectives, such as endoscopic or radiologic remission. However, even though biologics are highly effective, a significant percentage of patients will not achieve an initial response or may lose it over time. We know that there is a direct relationship between the trough concentrations of the biologic and its therapeutic efficacy, with more demanding therapeutic goals requiring higher drug levels, and inadequate exposure being common. Therapeutic drug monitoring of biologic medications, along with pharmacokinetic models, provides us with the possibility of offering a personalized approach to treatment for patients with IBD. Over the past few years, relevant information has accumulated regarding its utility during or after induction, as well as in the maintenance of biologic treatment, in reactive or proactive strategies, and prior to withdrawal or treatment de-escalation. The aim of this document is to establish recommendations regarding the utility of therapeutic drug monitoring of biologics in patients with inflammatory bowel disease, in different clinical practice scenarios, and to identify areas where its utility is evident, promising, or controversial.
Collapse
Affiliation(s)
- Francisco Rodríguez-Moranta
- Servicio de Aparato Digestivo, Hospital Universitario de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, España.
| | - Federico Argüelles-Arias
- Servicio de Aparato Digestivo, Hospital Universitario Virgen Macarena, Sevilla, España; Facultad de Medicina, Universidad de Sevilla, Sevilla, España
| | | | - Marisa Iborra Colomino
- Servicio de Aparato Digestivo, Hospital Universitario y Politécnico de La Fe, Valencia, España
| | - M Dolores Martín-Arranz
- Servicio de Aparato Digestivo, Hospital Universitario La Paz, Facultad de Medicina de la UAM, Fundación para la investigación del Hospital Universitario la Paz (IDIPAZ), Madrid, España
| | - Luis Menchén Viso
- Servicio de Aparato Digestivo, Hospital General Universitario Gregorio Marañón-IiSGM, Madrid, España; Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España
| | - Fernando Muñoz Núñez
- Servicio de Aparato Digestivo, Hospital Universitario de Salamanca, Salamanca, España
| | - Elena Ricart Gómez
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), H. Clínic Barcelona, Barcelona, IDIBAPS, Barcelona, España
| | | | - Teresa Valdés-Delgado
- Servicio de Aparato Digestivo, Hospital Universitario Virgen Macarena, Sevilla, España
| | - Jordi Guardiola Capón
- Servicio de Gastroenterología, Hospital Universitario de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, España
| | - Manuel Barreiro-de Acosta
- Servicio de Gastroenterología, Hospital Clínico Universitario de Santiago, A Coruña, España; Fundación Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), A Coruña, España
| | - Míriam Mañosa Ciria
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, España; Unidad de Enfermedad Inflamatoria Intestinal, Servicio de Gastroenterología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, España
| | - Yamile Zabana Abdo
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, España; Unidad de Enfermedad Inflamatoria Intestinal, Servicio de Gastroenterología, Hospital Mútua de Terrassa (HMT), Terrassa, Barcelona, España
| | - Ana Gutiérrez Casbas
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, España; Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, España
| |
Collapse
|
3
|
Sun M, Ju J, Xu H, Luo M, Li Z, Wang Y. Antibiotics influence the risk of anti-drug antibody formation during anti-TNF therapy in Chinese inflammatory bowel disease patients. Front Pharmacol 2024; 15:1360835. [PMID: 38655181 PMCID: PMC11035825 DOI: 10.3389/fphar.2024.1360835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 03/20/2024] [Indexed: 04/26/2024] Open
Abstract
Aims: The formation of anti-drug antibodies (ADAs) during anti-tumor necrosis factor (anti-TNF) therapy is reported to lead to reducing serum drug levels, which may bring about a loss of response to treatment. Previous research has suggested an association between specific antibiotic classes and ADA formation during anti-TNF therapy. However, there are few studies specifically examining this association in Chinese inflammatory bowel disease (IBD) patients. Therefore, our study aimed to evaluate the possible effect of antibiotic use on ADA formation to anti-TNF therapy in Chinese patients with IBD. Methods: A total of 166 patients with IBD, including 149 with Crohn's disease (CD) and 17 with ulcerative colitis (UC), were included in this retrospective analysis. These patients were initially treated with anti-TNF therapy (infliximab or adalimumab) after January 2018 and reviewed with available ADA levels before October 2023. After univariable analysis of all the variables, a multivariate Cox proportional hazards model was used to assess the association between antibiotic use and ADA development. Results: Among 166 IBD patients treated with infliximab (108/166, 65.1%) or adalimumab (58/166, 34.9%), 31 patients (18.7%) were measured as positive ADA levels. Cox proportional hazard model demonstrated an increased risk of ADA formation in IBD patients who used β-lactam-β-lactamase inhibitor combinations (BL-BLIs) (HR = 5.143, 95%CI 1.136-23.270, p = 0.033), or nitroimidazoles (HR = 4.635, 95%CI 1.641-13.089, p = 0.004) during 12 months before the ADA test. On the contrary, a reduced risk was noted in patients treated with fluoroquinolones (HR = 0.258, 95% CI 0.072-0.924, p = 0.037). Moreover, the median serum infliximab or adalimumab concentration in patients with positive ADA levels was significantly lower than that in patients with negative ADA levels (infliximab: 0.30 vs. 1.85 μg/mL, p < 0.0001; adalimumab: 0.45 vs. 7.55 μg/mL, p = 0.0121). Conclusion: ADA development is associated with various antibiotic classes. BL-BLIs and nitroimidazoles might increase the risk of ADA formation during anti-TNF therapy in Chinese IBD patients, while the treatment with fluoroquinolones could probably reduce such risk. There were certain limitations in the retrospective analysis of the study, therefore, the results are just for reference, and other studies are needed to further confirm our findings.
Collapse
Affiliation(s)
| | | | | | | | | | - Yufang Wang
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
4
|
Gensmyr-Singer H, Werner M, Karling P. The drug-survival of low-dose thioguanine in patients with inflammatory bowel disease: a retrospective observational study. Therap Adv Gastroenterol 2024; 17:17562848241228064. [PMID: 38384282 PMCID: PMC10880529 DOI: 10.1177/17562848241228064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 01/04/2024] [Indexed: 02/23/2024] Open
Abstract
Background Thiopurines are commonly used to treat inflammatory bowel disease but withdrawal due to side effects are common. Thioguanine has been suggested to be better tolerated than conventional thiopurines. Objectives We studied drug-survival of low dose of thioguanine in real-life clinical practice in comparison to conventional thiopurines. Design Retrospective observational study. Methods All patients born 1956 and later, and who at least once started thiopurine treatment between 2006 and 2022 were included. A medical chart review was performed that noted drug-survival for every thiopurine treatment attempt. The Mantel-Cox rank test was used to test differences in drug-survival for different thiopurines. Blood chemistry analysis and faecal calprotectin levels were registered for the first 5 years of treatment. Results In the study population, there was 379 initiated thiopurine treatments (210 for Crohn's disease and 169 for ulcerative colitis) in 307 patients with inflammatory bowel disease (IBD). Low-dose thioguanine (median dose 11 mg; 25-75th percentile 7-19 mg) had been initiated in 31 patients. Overall, when including all thiopurine attempts, thioguanine had the longest drug-survival [Mantel-Cox rank test: thioguanine versus azathioprine p = 0.014; thioguanine versus 6-mercaptopurine (6-MP) p < 0.001]. For second-line thiopurine treatment thioguanine had longer drug-survival than 6-MP (Mantel-Cox rank test: p = 0.006). At 60 months, 86% of the patients who started low-dose thioguanine were still on treatment compared to 42% of the patients who started 6-MP (p = 0.022). The median 6-thioguanine nucleotide levels in patients treated with thioguanine was 364 pmol/8 × 108. Patients on thioguanine treatment showed significantly lower values of median mean corpuscular volume at follow-up than patients treated with azathioprine and 6-MP. Patients treated with 6-MP showed significantly lower levels of FC in the third year of treatment compared to patient treated with azathioprine (59 versus 109 µg/g; p = 0.023), but there was no significant difference in FC levels for thioguanine compared to azathioprine (50 versus 109 µg/g; p = 0.33). Conclusion Treatment with a low dose of thioguanine is well-tolerated in patients with IBD and had a significantly higher drug-survival than conventional thiopurines.
Collapse
Affiliation(s)
| | - Mårten Werner
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Pontus Karling
- Department of Public Health and Clincal Medicine, Umeå University, Umeå S-90811, Sweden
| |
Collapse
|
5
|
González-Lama Y, Ricart E, Carpio D, Bastida G, Ceballos D, Ginard D, Marin-Jimenez I, Menchen L, Muñoz F. Controversies in the management of anti-TNF therapy in patients with Crohn's disease: a Delphi consensus. BMJ Open Gastroenterol 2024; 11:e001246. [PMID: 38267072 PMCID: PMC10870792 DOI: 10.1136/bmjgast-2023-001246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 10/24/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Despite research, there are still controversial areas in the management of Crohn's disease (CD). OBJECTIVE To establish practical recommendations on using anti-tumour necrosis factor (TNF) drugs in patients with moderate-to-severe CD. METHODS Clinical controversies in the management of CD using anti-TNF therapies were identified. A comprehensive literature review was performed, and a national survey was launched to examine current clinical practices when using anti-TNF therapies. Their results were discussed by expert gastroenterologists within a nominal group meeting, and a set of statements was proposed and tested in a Delphi process. RESULTS Qualitative study. The survey and Delphi process were sent to 244 CD-treating physicians (response rate: 58%). A total of 14 statements were generated. All but two achieved agreement. These statements cover: (1) use of first-line non-anti-TNF biological therapy; (2) role of HLA-DQA1*05 in daily practice; (3) attitudes in primary non-response and loss of response to anti-TNF therapy due to immunogenicity; (4) use of ustekinumab or vedolizumab if a change in action mechanism is warranted; (5) anti-TNF drug level monitoring; (6) combined therapy with an immunomodulator. CONCLUSION This document sought to pull together the best evidence, experts' opinions, and treating physicians' attitudes when using anti-TNF therapies in patients with CD.
Collapse
Affiliation(s)
- Yago González-Lama
- Gastroenterology Department, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | - Elena Ricart
- Gastroenterology Department, CIBEREHD, Madrid, Spain
| | - Daniel Carpio
- Gastroenterology Department, Complexo Hospitalario Universitario de Pontevedra, Pontevedra, Spain
| | | | - Daniel Ceballos
- Gastroenterology Department, Hospital Universitario Doctor Negrin, Las Palmas de Gran Canaria, Spain
| | - Daniel Ginard
- Gastroenterology Department, Hospital Universitario Son Espases, Palma, Spain
| | | | - Luis Menchen
- Gastroenterology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Fernando Muñoz
- Gastroenterology Department, Hospital Universitario de Salamanca, Salamanca, Spain
| |
Collapse
|
6
|
Anjie SI, Hanzel J, Gecse KB, D'Haens GR, Brandse JF. Anti-drug antibodies against anti-TNF in patients with inflammatory bowel disease: an evaluation of possible strategies. Scand J Gastroenterol 2024; 59:169-175. [PMID: 37961895 DOI: 10.1080/00365521.2023.2278424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/30/2023] [Indexed: 11/15/2023]
Abstract
OBJECTIVE Immunogenicity against anti-TNF antibodies usually leads to loss of response. We aimed to evaluate the efficacy of clinical strategies to improve clinical remission and pharmacokinetics upon detection of anti-drug antibodies (ADA). METHODS Inflammatory bowel disease (IBD) patients with ADA against infliximab or adalimumab were identified through a single centre database search covering 2004-2022. Criteria for successful intervention upon ADA detection (baseline) were clinical remission after 1 year without further change in strategy. RESULTS Two-hundred-and-fifty-five IBD patients (206 Crohn's disease) were identified. At baseline, median ADA level was 77 AU/ml; 50.2% of patients were in clinical remission. Implemented strategies were: (1) 81/255 (32%) conservative management, (2) 102/255 (40%) anti-TNF optimisation, (3) 72/255 (28%) switch within or out of class. Switching was the most successful strategy for clinical remission (from 19% at baseline to 69% at 1 year, p < 0.001). Patients that continued the same dose anti-TNF or discontinued biological therapy were often in clinical remission, but deteriorated significantly (-22.7%, p = 0.004). Anti-TNF dose intensification with immunomodulator optimisation was the fastest (median 3.0 months, p = 0.009) and most effective (65% ADA suppression, p < 0.001) strategy to suppress ADA compared to solely anti-TNF or immunomodulator optimisation. CONCLUSIONS Switching therapy, within or out of class, is the most successful strategy to regain and maintain clinical remission upon immunogenicity. When switching to another anti-TNF, concomitant immunomodulatory therapy should be started or continued to prevent repeated immunogenic loss of response. Anti-TNF dose escalation with concomitant immunomodulator optimisation is the fastest and most effective strategy to suppress ADA.
Collapse
Affiliation(s)
- Suzanne I Anjie
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Jurij Hanzel
- Department of Gastroenterology and Hepatology, Ljubljana University Medical Centre, Ljubljana, Slovenia
| | - Krisztina B Gecse
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Geert R D'Haens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Johannan F Brandse
- Department of Gastroenterology and Hepatology, Rijnstate, Arnhem, The Netherlands
| |
Collapse
|
7
|
Patel S, Yarur AJ. A Review of Therapeutic Drug Monitoring in Patients with Inflammatory Bowel Disease Receiving Combination Therapy. J Clin Med 2023; 12:6577. [PMID: 37892715 PMCID: PMC10607463 DOI: 10.3390/jcm12206577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 09/27/2023] [Accepted: 10/14/2023] [Indexed: 10/29/2023] Open
Abstract
Background: Inflammatory Bowel Disease (IBD) impacts millions worldwide, presenting a major challenge to healthcare providers and patients. The advent of biologic therapies has enhanced the prognosis, but many patients exhibit primary or secondary non-response, underscoring the need for rigorous monitoring and therapy optimization to improve outcomes. Objective: This narrative review seeks to understand the role of therapeutic drug monitoring (TDM) in optimizing treatment for IBD patients, especially for those on combination therapies of biologics and immunomodulators. Methods: A comprehensive synthesis of the current literature was undertaken, focusing on the application, benefits, limitations, and future directions of TDM in patients receiving a combination of biologic therapies and immunomodulators. Results: While biological therapies have improved outcomes, rigorous monitoring and therapy optimization are needed. TDM has emerged as a pivotal strategy, enhancing outcomes cost-effectively while reducing adverse events. While most data pertain to monotherapies, TDM's applicability also extends to combination therapy. Conclusion: TDM plays a crucial role in the treatment optimization of IBD patients on combination therapies. Further research is needed to fully understand its potential and limitations in the broader context of IBD management.
Collapse
Affiliation(s)
| | - Andres J. Yarur
- Cedars-Sinai Medical Center, 8730 Alden Dr., Los Angeles, CA 90048, USA
| |
Collapse
|
8
|
Kucharzik T, Dignass A, Atreya R, Bokemeyer B, Esters P, Herrlinger K, Kannengiesser K, Kienle P, Langhorst J, Lügering A, Schreiber S, Stallmach A, Stein J, Sturm A, Teich N, Siegmund B. Aktualisierte S3-Leitlinie Colitis ulcerosa (Version 6.1) – Februar 2023 – AWMF-Registriernummer: 021-009. Z Gastroenterol 2023; 61:1046-1134. [PMID: 37579791 DOI: 10.1055/a-2060-0935] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Affiliation(s)
- T Kucharzik
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Städtisches Klinikum Lüneburg, Lüneburg, Deutschland
| | - A Dignass
- Medizinische Klinik I, Agaplesion Markus Krankenhaus, Frankfurt, Deutschland
| | - R Atreya
- Medizinische Klinik 1 Gastroent., Pneumologie, Endokrin., Universitätsklinikum Erlangen, Erlangen, Deutschland
| | - B Bokemeyer
- Interdisziplinäres Crohn Colitis Centrum Minden - ICCCM, Minden, Deutschland
| | - P Esters
- Medizinische Klinik I, Agaplesion Markus Krankenhaus, Frankfurt, Deutschland
| | - K Herrlinger
- Innere Medizin I, Asklepios Klinik Nord, Hamburg, Deutschland
| | - K Kannengiesser
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Städtisches Klinikum Lüneburg, Lüneburg, Deutschland
| | - P Kienle
- Abteilung für Allgemein- und Viszeralchirurgie, Theresienkrankenhaus, Mannheim, Deutschland
| | - J Langhorst
- Klinik für Integrative Medizin und Naturheilkunde, Sozialstiftung Bamberg Klinikum am Bruderwald, Bamberg, Deutschland
| | - A Lügering
- Medizinisches Versorgungszentrum Portal 10, Münster, Deutschland
| | - S Schreiber
- Klinik für Innere Medizin I, Universitätsklinikum Schleswig Holstein, Kiel, Deutschland
| | - A Stallmach
- Klinik für Innere Medizin IV Gastroenterologie, Hepatologie, Infektiologie, Universitätsklinikum Jena, Jena, Deutschland
| | - J Stein
- Abteilung Innere Medizin mit Schwerpunkt Gastroenterologie, Krankenhaus Sachsenhausen, Frankfurt, Deutschland
| | - A Sturm
- Klinik für Innere Medizin mit Schwerpunkt Gastroenterologie, DRK Kliniken Berlin Westend, Berlin, Deutschland
| | - N Teich
- Internistische Gemeinschaftspraxis, Leipzig, Deutschland
| | - B Siegmund
- Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Charité Campus Benjamin Franklin - Universitätsmedizin Berlin, Berlin, Deutschland
| |
Collapse
|
9
|
Demase K, Monitto CK, Little RD, Sparrow MP. The Role of Low-Dose Oral Methotrexate in Increasing Anti-TNF Drug Levels and Reducing Immunogenicity in IBD. J Clin Med 2023; 12:4382. [PMID: 37445417 DOI: 10.3390/jcm12134382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
Concomitant immunomodulation is utilised in combination with anti-TNF therapy for IBD primarily to increase drug levels and prevent anti-drug antibody formation. Whilst thiopurines have traditionally been the immunomodulator of choice in IBD populations, there are concerns regarding the long-term safety of the prolonged use of these agents: particularly an association with lymphoproliferative disorders. Given this, we have explored the existing literature on the use of low-dose oral methotrexate as an alternative immunomodulator for this indication. Although there is a lack of data directly comparing the efficacies of methotrexate and thiopurines as concomitant immunomodulators, the available literature supports the use of methotrexate in improving the pharmacokinetics of anti-TNF agents. Furthermore, low-dose oral methotrexate regimens appear to have comparable efficacies to higher-dose parenteral administration and are better tolerated. We suggest that clinicians should consider the use of low-dose oral methotrexate as an alternative to thiopurines when the primary purpose of concomitant immunomodulation is to improve anti-TNF pharmacokinetics.
Collapse
Affiliation(s)
- Kathryn Demase
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne 3004, Australia
| | - Cassandra K Monitto
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne 3004, Australia
- Department of Pharmacy, Alfred Health, Melbourne 3004, Australia
| | - Robert D Little
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne 3004, Australia
| | - Miles P Sparrow
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne 3004, Australia
| |
Collapse
|
10
|
Stallhofer J, Guse J, Kesselmeier M, Grunert PC, Lange K, Stalmann R, Eckardt V, Stallmach A. Immunomodulator comedication promotes the reversal of anti-drug antibody-mediated loss of response to anti-TNF therapy in inflammatory bowel disease. Int J Colorectal Dis 2023; 38:54. [PMID: 36840779 PMCID: PMC9968255 DOI: 10.1007/s00384-023-04349-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/13/2023] [Indexed: 02/26/2023]
Abstract
PURPOSE Loss of therapeutic response (LOR) due to anti-drug antibodies (ADA) against tumor necrosis factor (TNF) inhibitors is common in patients with inflammatory bowel disease (IBD). We aimed to investigate whether immunomodulator comedication can reverse the immunogenic LOR to TNF inhibitors in IBD. METHODS In this real-world retrospective cohort study, 123 IBD patients with neutralizing ADA to infliximab or adalimumab and concomitant subtherapeutic trough levels were screened for clinical LOR. Subsequent ADA and trough level measurements and clinical outcomes were analyzed for patients who received either immunomodulator comedication or dose intensification of infliximab or adalimumab to overcome LOR. RESULTS Following immunogenic LOR, the initial anti-TNF regimen was optimized in 33 patients. In univariable and multivariable logistic regression analyses, immunomodulator comedication was identified as the crucial factor for regaining clinical remission and ADA clearance. Detectable trough levels (≥ 0.98 or ≥ 1.00 mg/L, respectively) had optimal predictive performance for both endpoints in receiver operating characteristics curves [area under the curve 0.86 (95% confidence interval 0.68-1.00) for regaining clinical remission, 0.87 (0.71-1.00) for ADA clearance]. Furthermore, 11/20 patients (55%) on a comedication with azathioprine or methotrexate and 2/13 patients (15%) receiving anti-TNF dose intensification exclusively (P = 0.032) exhibited ADA elimination, regain of therapeutic trough levels, and clinical remission. Regain of clinical remission alone was achieved in 17/20 (85%) patients receiving comedication and 2/13 (15%) patients receiving anti-TNF dose intensification (P = 1.6 × 10-4). CONCLUSION Immunogenic LOR to infliximab or adalimumab in IBD can be successfully reversed using immunomodulator comedication.
Collapse
Affiliation(s)
- Johannes Stallhofer
- Department of Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases), Jena University Hospital, Am Klinikum 1, Jena, 07747, Germany.
| | - Jan Guse
- Department of Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases), Jena University Hospital, Am Klinikum 1, Jena, 07747, Germany
| | - Miriam Kesselmeier
- Institute of Medical Statistics, Computer and Data Sciences, Jena University Hospital, Jena, Germany
| | - Philip Christian Grunert
- Department of Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases), Jena University Hospital, Am Klinikum 1, Jena, 07747, Germany
| | - Kathleen Lange
- Department of Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases), Jena University Hospital, Am Klinikum 1, Jena, 07747, Germany
| | - Robert Stalmann
- Institute of Clinical Chemistry and Laboratory Diagnostics, Centralized Diagnostic Laboratory Services, Jena University Hospital, Jena, Germany
| | - Verena Eckardt
- Institute of Clinical Chemistry and Laboratory Diagnostics, Centralized Diagnostic Laboratory Services, Jena University Hospital, Jena, Germany
| | - Andreas Stallmach
- Department of Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases), Jena University Hospital, Am Klinikum 1, Jena, 07747, Germany
| |
Collapse
|
11
|
Kampa KC, Loures MR, Ivantes CAP, Petterle RR, Pedroso MLA. THE EVALUATION OF INFLIXIMAB TROUGH LEVEL FAVORS MAINTENANCE THERAPY OF PATIENTS WITH INFLAMMATORY BOWEL DISEASE. Arq Gastroenterol 2023; 60:48-56. [PMID: 37194780 DOI: 10.1590/s0004-2803.202301000-07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 12/16/2022] [Indexed: 05/18/2023]
Abstract
BACKGROUND Crohn's disease (CD) and ulcerative colitis (UC) are chronic diseases that result from the deregulation of the mucosal immune system of the gastrointestinal tract. The use of biological therapies, including infliximab (IFX), is one of the strategies to treat both CD and UC. The IFX treatment is monitored by complementary tests, namely: fecal calprotectin (FC); C-reactive protein (CRP); and endoscopic and cross-sectional imaging. Besides, serum IFX evaluation and antibody detection are also used. OBJECTIVE To evaluate trough levels (TL) and antibodies in a population with inflammatory bowel (IBD) disease undergoing treatment with IFX, and the factors that might impact the treatment effectiveness. METHODS Retrospective, cross-sectional study with patients with IBD that were assessed for TL and antibody (ATI) levels in a southern Brazilian hospital, from June 2014 to July 2016. RESULTS The study assessed 55 patients (52.7% female) submitted to serum IFX and antibody evaluations (95 blood samples, 55 first test; 30 second test, and 10 as third testing. Forty-five (47.3%) cases were diagnosed with CD (81.8%), and ten with UC (18.2%). Serum levels were adequate in 30 samples (31.57%), subtherapeutic in 41 (43.15%), and supratherapeutic in 24 (25.26%). IFX dosages were optimized for 40 patients (42.10%), maintained for 31 (32.63%), and discontinued for 7 (7.60%). The intervals between infusions were shortened in 17.85% of the cases. In 55 tests (55.79%), the therapeutic approach was exclusively defined according to IFX and/or serum antibody levels. The assessment of patients one year later indicated that: the approach was maintained with IFX for thirty-eight patients (69.09%); the class of biological agent was changed for eight (14.54%); changes using the same class of biological agent occurred for two patients (3.63%); the medication was discontinued and not replaced for three patients (5.45%), and four patients (7.27%) were lost to follow-up. CONCLUSION There were no differences in TL between groups with or without immunosuppressants, serum albumin (ALB), erythrocyte sedimentation rate (ESR), FC, CRP, and endoscopic and imaging examinations. Current therapeutic approach could be maintained for almost 70% of patients. Thus, serum and antibody levels are a useful tool in the follow-up of patients undergoing maintenance therapy and after treatment induction in patients with inflammatory bowel disease.
Collapse
Affiliation(s)
- Katia Cristina Kampa
- Universidade Federal do Paraná, Complexo Hospital de Clínicas, Curitiba, PR, Brasil
- Hospital Nossa Senhora das Graças, Curitiba, PR, Brasil
| | | | | | | | | |
Collapse
|
12
|
Miraldi Utz V, Angeles-Han ST, Mwase N, Cassedy A, Hennard T, Lovell DJ, Lopper S, Brunner HI, Dosunmu EO, Grom AA, Henrickson M, Huggins JL, Sisk RA, Ting TV, Kaufman AH. Alternative Biologic Therapy in Children Failing Conventional TNFα Inhibitors for Refractory, Noninfectious, Chronic Anterior Uveitis. Am J Ophthalmol 2022; 244:183-195. [PMID: 35863492 DOI: 10.1016/j.ajo.2022.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 06/25/2022] [Accepted: 06/30/2022] [Indexed: 01/30/2023]
Abstract
PURPOSE A significant number of children with noninfectious, chronic anterior uveitis (CAU) fail to respond to conventional therapy; however, successful alternative biologic treatments (ABT) have not been well described. This study aims to review the clinical and treatment characteristics of children with CAU who require ABT. DESIGN Retrospective, nonrandomized clinical study. METHODS Setting: Tertiary center. STUDY POPULATION Children with noninfectious CAU. OBSERVATION PROCEDURES Clinical characteristics, uveitis course, complications, and treatment were compared among patients treated with methotrexate (MTX) monotherapy, conventional TNFα inhibitors (cTNFi), and ABT for >3 months. MAIN OUTCOME MEASURE Success of ABT (abatacept, tocilizumab, and/or golimumab) in children failing conventional treatment. RESULTS Of the 52 children with CAU, 75% had juvenile idiopathic arthritis. CAU was controlled in 15 children receiving MTX monotherapy, 28 receiving cTNFi, and 9 receiving ABT (n = 1, abatacept; n = 3, tocilizumab; n = 5, golimumab). Patients in the ABT group had a greater number of total ocular complications per person before ABT than those in the control groups (3.4 vs 0.7 [MTX], P < .001, and 1.5 [cTNFi], P < .001, respectively). In all 9 children on ABT, treatment led to control of CAU and topical glucocorticoids tapered to ≤2 drops/d with no new ocular complications. CONCLUSIONS In this study, alternative biologics (abatacept, golimumab, and tocilizumab) were useful for treating CAU in children who fail MTX and cTNFi therapy. Patients who were controlled on ABT had more disease activity, ocular complications, and anti-cTNFi neutralizing antibodies (before ABT) than those managed with conventional therapy. Larger studies are required to confirm these findings.
Collapse
Affiliation(s)
- Virginia Miraldi Utz
- From the Abrahamson Pediatric Eye Institute, Cincinnati Children's Hospital Medical Center (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.)
| | - Sheila T Angeles-Han
- From the Abrahamson Pediatric Eye Institute, Cincinnati Children's Hospital Medical Center (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.); Department of Ophthalmology (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.); Division of Rheumatology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics (S.T.A.-H., N.M., T.H., D.J.L., H.I.B., A.A.G., M.H., J.L.H., T.V.T.).
| | - Najima Mwase
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics (S.T.A.-H., N.M., T.H., D.J.L., H.I.B., A.A.G., M.H., J.L.H., T.V.T.)
| | - Amy Cassedy
- University of Cincinnati, and Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center (A.C.)
| | - Theresa Hennard
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics (S.T.A.-H., N.M., T.H., D.J.L., H.I.B., A.A.G., M.H., J.L.H., T.V.T.)
| | - Daniel J Lovell
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics (S.T.A.-H., N.M., T.H., D.J.L., H.I.B., A.A.G., M.H., J.L.H., T.V.T.)
| | - Sarah Lopper
- From the Abrahamson Pediatric Eye Institute, Cincinnati Children's Hospital Medical Center (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.); Department of Ophthalmology (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.)
| | - Hermine I Brunner
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics (S.T.A.-H., N.M., T.H., D.J.L., H.I.B., A.A.G., M.H., J.L.H., T.V.T.)
| | - Eniolami O Dosunmu
- From the Abrahamson Pediatric Eye Institute, Cincinnati Children's Hospital Medical Center (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.); Department of Ophthalmology (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.)
| | - Alexei A Grom
- From the Abrahamson Pediatric Eye Institute, Cincinnati Children's Hospital Medical Center (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.)
| | - Michael Henrickson
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics (S.T.A.-H., N.M., T.H., D.J.L., H.I.B., A.A.G., M.H., J.L.H., T.V.T.)
| | - Jennifer L Huggins
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics (S.T.A.-H., N.M., T.H., D.J.L., H.I.B., A.A.G., M.H., J.L.H., T.V.T.)
| | - Robert A Sisk
- From the Abrahamson Pediatric Eye Institute, Cincinnati Children's Hospital Medical Center (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.); Department of Ophthalmology (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.); Cincinnati Eye Institute (R.A.S., A.H.K.), Cincinnati, Ohio, USA
| | - Tracy V Ting
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics (S.T.A.-H., N.M., T.H., D.J.L., H.I.B., A.A.G., M.H., J.L.H., T.V.T.)
| | - Adam H Kaufman
- From the Abrahamson Pediatric Eye Institute, Cincinnati Children's Hospital Medical Center (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.); Department of Ophthalmology (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.); Cincinnati Eye Institute (R.A.S., A.H.K.), Cincinnati, Ohio, USA
| |
Collapse
|
13
|
Ruiz-Cerulla A, Rodríguez-Alonso L, Rodríguez-Moranta F, Guardiola J. A high adalimumab induction dosing regimen achieves clinical and endoscopic remission in super-refractory ulcerative colitis. Gastroenterol Hepatol 2022; 45:780-781. [PMID: 35278502 DOI: 10.1016/j.gastrohep.2022.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/18/2022] [Accepted: 02/28/2022] [Indexed: 01/20/2023]
Affiliation(s)
- Alexandra Ruiz-Cerulla
- Department of Gastroenterology, Hospital Universitari de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Lorena Rodríguez-Alonso
- Department of Gastroenterology, Hospital Universitari de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Francisco Rodríguez-Moranta
- Department of Gastroenterology, Hospital Universitari de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Jordi Guardiola
- Department of Gastroenterology, Hospital Universitari de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| |
Collapse
|
14
|
Barrau M, Duprat M, Veyrard P, Tournier Q, Williet N, Phelip JM, Waeckel L, Cheifetz AS, Papamichael K, Roblin X, Paul S. A Systematic Review on the interest of Drug Tolerant assay in the monitoring of Inflammatory Bowel Disease. J Crohns Colitis 2022; 17:633-643. [PMID: 36301958 DOI: 10.1093/ecco-jcc/jjac164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Indexed: 02/08/2023]
Abstract
Many patients with inflammatory bowel disease (IBD) are treated with anti-tumor necrosis factor (TNF) therapies, of which infliximab (IFX) is most commonly used. Loss of response (LOR) to anti-TNF therapy due to immunogenic failure accounts for 20% of subsequent medical intervention and is defined, using a drug sensitive assay, as low or undetectable concentration of drug with high titers of anti-drug antibodies (ADAb). We performed a systematic review to investigate the use of a drug tolerant assay during both induction and maintenance to monitor patients treated with anti-TNFs. After the search on PubMed, 90 publications were reviewed. Most ADAb detection methods are drug sensitive, cannot detect ADAb in the presence of drug, and therefore cannot be used close to drug administration, when the drug concentration is too high. To overcome this major limitation, several drug-tolerant techniques have been developed and will be discussed in this review. Using drug-tolerant assays ADAb against infliximab (IFX) or adalimumab (ADM) can be detected during induction and predict primary non-response or LOR. Drug sensitive assays do not allow detection of ADAb during the induction phase as IFX or ADM concentration is typically high.
Collapse
Affiliation(s)
- Mathilde Barrau
- Department of Gastroenterology, University Hospital of Saint Etienne, Saint Etienne, France
| | - Manon Duprat
- Department of Immunology, CIRI - Centre International de Recherche en Infectiologie, Team GIMAP, Univ Lyon, Université Claude Bernard Lyon 1, Inserm, U1111, CNRS, UMR530, CIC 1408 Vaccinology, F42023 Saint-Etienne, France
| | - Pauline Veyrard
- Department of Gastroenterology, University Hospital of Saint Etienne, Saint Etienne, France
| | - Quentin Tournier
- Department of Gastroenterology, University Hospital of Saint Etienne, Saint Etienne, France
| | - Nicolas Williet
- Department of Gastroenterology, University Hospital of Saint Etienne, Saint Etienne, France
| | - Jean Marc Phelip
- Department of Gastroenterology, University Hospital of Saint Etienne, Saint Etienne, France
| | - Louis Waeckel
- Department of Immunology, CIRI - Centre International de Recherche en Infectiologie, Team GIMAP, Univ Lyon, Université Claude Bernard Lyon 1, Inserm, U1111, CNRS, UMR530, CIC 1408 Vaccinology, F42023 Saint-Etienne, France
| | - Adam S Cheifetz
- Center for Inflammatory Bowel Disease, Beth Israel Deaconess Medical Center Instructor in Medicine, Harvard Medical School
| | - Konstantinos Papamichael
- Center for Inflammatory Bowel Disease, Beth Israel Deaconess Medical Center Instructor in Medicine, Harvard Medical School
| | - Xavier Roblin
- Department of Gastroenterology, University Hospital of Saint Etienne, Saint Etienne, France
| | - Stephane Paul
- Department of Immunology, CIRI - Centre International de Recherche en Infectiologie, Team GIMAP, Univ Lyon, Université Claude Bernard Lyon 1, Inserm, U1111, CNRS, UMR530, CIC 1408 Vaccinology, F42023 Saint-Etienne, France
| |
Collapse
|
15
|
Chanchlani N, Lin S, Auth MK, Lee CL, Robbins H, Looi S, Murugesan SV, Riley T, Preston C, Stephenson S, Cardozo W, Sonwalkar SA, Allah‐Ditta M, Mansfield L, Durai D, Baker M, London I, London E, Gupta S, Di Mambro A, Murphy A, Gaynor E, Jones KDJ, Claridge A, Sebastian S, Ramachandran S, Selinger CP, Borg‐Bartolo SP, Knight P, Sprakes MB, Burton J, Kane P, Lupton S, Fletcher A, Gaya DR, Colbert R, Seenan JP, MacDonald J, Lynch L, McLachlan I, Shields S, Hansen R, Gervais L, Jere M, Akhtar M, Black K, Henderson P, Russell RK, Lees CW, Derikx LAAP, Lockett M, Betteridge F, De Silva A, Hussenbux A, Beckly J, Bendall O, Hart JW, Thomas A, Hamilton B, Gordon C, Chee D, McDonald TJ, Nice R, Parkinson M, Gardner‐Thorpe H, Butterworth JR, Javed A, Al‐Shakhshir S, Yadagiri R, Maher S, Pollok RCG, Ng T, Appiahene P, Donovan F, Lok J, Chandy R, Jagdish R, Baig D, Mahmood Z, Marsh L, Moss A, Abdulgader A, Kitchin A, Walker GJ, George B, Lim Y, Gulliver J, Bloom S, Theaker H, Carlson S, Cummings JRF, Livingstone R, Beale A, Carter JO, Bell A, Coulter A, Snook J, Stone H, Kennedy NA, Goodhand JR, Ahmad T. Implications for sequencing of biologic therapy and choice of second anti-TNF in patients with inflammatory bowel disease: results from the IMmunogenicity to Second Anti-TNF therapy (IMSAT) therapeutic drug monitoring study. Aliment Pharmacol Ther 2022; 56:1250-1263. [PMID: 36039036 PMCID: PMC9804266 DOI: 10.1111/apt.17170] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 07/05/2022] [Accepted: 07/19/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND Anti-drug antibodies are associated with treatment failure to anti-TNF agents in patients with inflammatory bowel disease (IBD). AIM To assess whether immunogenicity to a patient's first anti-TNF agent would be associated with immunogenicity to the second, irrespective of drug sequence METHODS: We conducted a UK-wide, multicentre, retrospective cohort study to report rates of immunogenicity and treatment failure of second anti-TNF therapies in 1058 patients with IBD who underwent therapeutic drug monitoring for both infliximab and adalimumab. The primary outcome was immunogenicity to the second anti-TNF agent, defined at any timepoint as an anti-TNF antibody concentration ≥9 AU/ml for infliximab and ≥6 AU/ml for adalimumab. RESULTS In patients treated with infliximab and then adalimumab, those who developed antibodies to infliximab were more likely to develop antibodies to adalimumab, than patients who did not develop antibodies to infliximab (OR 1.99, 95%CI 1.27-3.20, p = 0.002). Similarly, in patients treated with adalimumab and then infliximab, immunogenicity to adalimumab was associated with subsequent immunogenicity to infliximab (OR 2.63, 95%CI 1.46-4.80, p < 0.001). For each 10-fold increase in anti-infliximab and anti-adalimumab antibody concentration, the odds of subsequently developing antibodies to adalimumab and infliximab increased by 1.73 (95% CI 1.38-2.17, p < 0.001) and 1.99 (95%CI 1.34-2.99, p < 0.001), respectively. Patients who developed immunogenicity with undetectable drug levels to infliximab were more likely to develop immunogenicity with undetectable drug levels to adalimumab (OR 2.37, 95% CI 1.39-4.19, p < 0.001). Commencing an immunomodulator at the time of switching to the second anti-TNF was associated with improved drug persistence in patients with immunogenic, but not pharmacodynamic failure. CONCLUSION Irrespective of drug sequence, immunogenicity to the first anti-TNF agent was associated with immunogenicity to the second, which was mitigated by the introduction of an immunomodulator in patients with immunogenic, but not pharmacodynamic treatment failure.
Collapse
|
16
|
Marsal J, Barreiro-de Acosta M, Blumenstein I, Cappello M, Bazin T, Sebastian S. Management of Non-response and Loss of Response to Anti-tumor Necrosis Factor Therapy in Inflammatory Bowel Disease. Front Med (Lausanne) 2022; 9:897936. [PMID: 35783628 PMCID: PMC9241563 DOI: 10.3389/fmed.2022.897936] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 05/25/2022] [Indexed: 11/30/2022] Open
Abstract
Anti-tumor necrosis factor (anti-TNF) therapy has been successfully used as first-line biologic treatment for moderate-to-severe inflammatory bowel disease (IBD), in both “step-up” and “top-down” approaches, and has become a cornerstone of IBD management. However, in a proportion of patients the effectiveness of anti-TNF therapy is sub-optimal. Either patients do not achieve adequate initial response (primary non-response) or they lose response after initial success (loss of response). Therapeutic drug monitoring determines drug serum concentrations and the presence of anti-drug antibodies (ADAbs) and can help guide treatment optimization to improve patient outcomes. For patients with low drug concentrations who are ADAb-negative or display low levels of ADAbs, dose escalation is recommended. Should response remain unchanged following dose optimization the question whether to switch within class (anti-TNF) or out of class (different mechanism of action) arises. If ADAb levels are high and the patient has previously benefited from anti-TNF therapy, then switching within class is a viable option as ADAbs are molecule specific. Addition of an immunomodulator may lead to a decrease in ADAbs and a regaining of response in a proportion of patients. If a patient does not achieve a robust therapeutic response with an initial anti-TNF despite adequate drug levels, then switching out of class is appropriate. In conjunction with the guidance above, other factors including patient preference, age, comorbidities, disease phenotype, extra-intestinal manifestations, and treatment costs need to be factored into the treatment decision. In this review we discuss current evidence in this field and provide guidance on therapeutic decision-making in clinical situations.
Collapse
Affiliation(s)
- Jan Marsal
- Department of Gastroenterology, Skåne University Hospital, Lund/Malmö, Sweden
- Department of Immunology, Lund University, Lund, Sweden
- *Correspondence: Jan Marsal,
| | - Manuel Barreiro-de Acosta
- Gastroenterology Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Irina Blumenstein
- Department of Internal Medicine 1, Gastroenterology, Hepatology and Clinical Nutrition, University Clinic Frankfurt, Frankfurt, Germany
| | - Maria Cappello
- Gastroenterology and Hepatology Section, Promise, University of Palermo, Palermo, Italy
| | - Thomas Bazin
- Department of Gastroenterology, Université Paris Saclay/UVSQ, INSERM, Infection and Inflammation, UMR 1173, AP-HP, Hôpital Ambroise Paré, Boulogne Billancourt, France
| | - Shaji Sebastian
- Inflammatory Bowel Disease (IBD) Unit, Hull University Teaching Hospitals National Health Service (NHS) Trust, Hull, United Kingdom
| |
Collapse
|
17
|
Irving PM, Gecse KB. Optimizing Therapies Using Therapeutic Drug Monitoring: Current Strategies and Future Perspectives. Gastroenterology 2022; 162:1512-1524. [PMID: 35167865 DOI: 10.1053/j.gastro.2022.02.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/08/2022] [Accepted: 02/09/2022] [Indexed: 01/07/2023]
Abstract
Therapeutic drug monitoring (TDM) has emerged as a strategy for treatment optimization in inflammatory bowel diseases to maximize benefit and to reach more stringent, objective end points. Optimal drug concentrations in inflammatory bowel disease vary according to treatment target, disease phenotype, inflammatory burden, and timing of sampling during the treatment cycle. This review provides an update on TDM with biologic and oral small molecules, evaluates the role of reactive vs proactive TDM, and identifies the gaps in current evidence. In the future, adaptations to how we use TDM may contribute further to the goal of personalized treatment in patients with IBD.
Collapse
Affiliation(s)
- Peter M Irving
- IBD Unit, Department of Gastroenterology, Guy's and St Thomas' Hospital, London, United Kingdom; School of Immunology and Microbial Sciences, King's College London, London, United Kingdom.
| | - Krisztina B Gecse
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Amsterdam, the Netherlands
| |
Collapse
|
18
|
Cassinotti A, Batticciotto A, Parravicini M, Lombardo M, Radice P, Cortelezzi CC, Segato S, Zanzi F, Cappelli A, Segato S. Evidence-based efficacy of methotrexate in adult Crohn's disease in different intestinal and extraintestinal indications. Therap Adv Gastroenterol 2022; 15:17562848221085889. [PMID: 35340755 PMCID: PMC8949794 DOI: 10.1177/17562848221085889] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 02/18/2022] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Methotrexate (MTX) is included in the therapeutic armamentarium of Crohn's disease (CD), although its positioning is currently uncertain in an era in which many effective biological drugs are available. No systematic reviews or meta-analysis have stratified the clinical outcomes of MTX according to the specific clinical scenarios of its use. METHODS Medline, PubMed and Scopus were used to extract eligible studies, from database inception to May 2021. A total of 163 studies were included. A systematic review was performed by stratifying the outcomes of MTX according to formulation, clinical indication and criteria of efficacy. RESULTS The use of MTX is supported by randomized clinical trials only in steroid-dependent CD, with similar outcomes to thiopurines. The use of MTX in patients with steroid-refractoriness, failure of thiopurines or in combination with biologics is not supported by high levels of evidence. Combination therapy with biologics can optimize the immunogenic profile of the biological drug, but the impact on long-term clinical outcomes is described only in small series with anti-TNFα. Other off-label uses, such as fistulizing disease, mucosal healing, postoperative prevention and extraintestinal manifestations, are described in small uncontrolled series. The best performance in most indications was shown by parenteral MTX, favouring higher doses (25 mg/week) in the induction phase. DISCUSSION Evidence from high-quality studies in favour of MTX is scarce and limited to the steroid-dependent disease, in which other drugs are the leading players today. Many limitations on study design have been found, such as the prevalence of retrospective underpowered studies and the lack of stratification of outcomes according to specific types of patients and formulations of MTX. CONCLUSION MTX is a valid option as steroid-sparing agent in steroid-dependent CD. Numerous other clinical scenarios require well-designed clinical studies in terms of patient profile, drug formulation and dosage, and criteria of efficacy.
Collapse
Affiliation(s)
| | | | | | | | - Paolo Radice
- Ophtalmology Unit, ASST Sette Laghi, Varese, Italy
| | | | - Simone Segato
- Gastroenterology Unit, ASST Sette Laghi, Varese, Italy
| | | | | | - Sergio Segato
- Gastroenterology Unit, ASST Sette Laghi, Varese, Italy
| |
Collapse
|
19
|
Gorelik Y, Freilich S, Gerassy-Vainberg S, Pressman S, Friss C, Blatt A, Focht G, Weisband YL, Greenfeld S, Kariv R, Lederman N, Dotan I, Geva-Zatorsky N, Shen-Orr SS, Kashi Y, Chowers Y. Antibiotic use differentially affects the risk of anti-drug antibody formation during anti-TNFα therapy in inflammatory bowel disease patients: a report from the epi-IIRN. Gut 2022; 71:287-295. [PMID: 34344783 PMCID: PMC8762017 DOI: 10.1136/gutjnl-2021-325185] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 07/21/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Anti-drug antibodies (ADA) to anti-tumour necrosis factor (anti-TNF) therapy drive treatment loss of response. An association between intestinal microbial composition and response to anti-TNF therapy was noted. We therefore aimed to assess the implications of antibiotic treatments on ADA formation in patients with inflammatory bowel disease (IBD). DESIGN We analysed data from the epi-IIRN (epidemiology group of the Israeli IBD research nucleus), a nationwide registry of all patients with IBD in Israel. We included all patients treated with anti-TNF who had available ADA levels. Survival analysis with drug use as time varying covariates were used to assess the association between antibiotic use and ADA development. Next, specific pathogen and germ-free C57BL mice were treated with respective antibiotics and challenged with infliximab. ADA were assessed after 14 days. RESULTS Among 1946 eligible patients, with a median follow-up of 651 days from initiation of therapy, 363 had positive ADA. Cox proportional hazard model demonstrated an increased risk of ADA development in patients who used cephalosporins (HR=1.97, 95% CI 1.58 to 2.44), or penicillins with β-lactamase inhibitors (penicillin-BLI, HR=1.4, 95% CI 1.13 to 1.74), whereas a reduced risk was noted in patients treated with macrolides (HR=0.38, 95% CI 0.16 to 0.86) or fluoroquinolones (HR=0.20, 95% CI 0.12 to 0.35). In mice exposed to infliximab, significantly increased ADA production was observed in cephalosporin as compared with macrolide pretreated mice. Germ-free mice produced no ADA. CONCLUSION ADA production is associated with the microbial composition. The risk of ADA development during anti-TNF therapy can possibly be reduced by avoidance of cephalosporins and penicillin-BLIs, or by treatment with fluoroquinolones or macrolides.
Collapse
Affiliation(s)
- Yuri Gorelik
- Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Shay Freilich
- Faculty of Biotechnology and Food Engineering, Technion Israel Institute of Technology, Haifa, Israel,Clinical Research Institute, Rambam Health Care Campus, Haifa, Israel
| | - Shiran Gerassy-Vainberg
- Clinical Research Institute, Rambam Health Care Campus, Haifa, Israel,Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Sigal Pressman
- Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Chagit Friss
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, The Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Gili Focht
- The Juliet Keiden Institute of Pediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, Jerusalem, Israel
| | | | - Shira Greenfeld
- Medical Informatics, Maccabi Health Services, Tel Aviv, Israel,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Revital Kariv
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel,Gastroenterology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Nathan Lederman
- Gastroenterology, Meuhedet Health Services, Jerusalem, Israel
| | - Iris Dotan
- Gastroenterology, Rabin Medical Center, Petah Tikva, Israel,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Naama Geva-Zatorsky
- Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel,Rappaport Technion Integrated Cancer Center (RTICC), Technion Israel Institute of Technology, Haifa, Israel
| | | | - Yechezkel Kashi
- Faculty of Biotechnology and Food Engineering, Technion Israel Institute of Technology, Haifa, Israel
| | - Yehuda Chowers
- Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | | |
Collapse
|
20
|
Yanai H, Ungar B, Kopylov U, Fischler TS, Biron IA, Ollech JE, Goren I, Matar M, Perets TT, Shamir R, Dotan I, Amir S, Assa A. Risk of consecutive immunogenic failure in switchers of anti-tumor necrosis factor alpha among patients with inflammatory bowel diseases. Therap Adv Gastroenterol 2022; 15:17562848211068659. [PMID: 35082920 PMCID: PMC8785344 DOI: 10.1177/17562848211068659] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 12/03/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Evidence regarding the risk of immunogenicity in patients with inflammatory bowel disease (IBD) who switched anti-tumor necrosis factor alpha (anti-TNFα) therapies to a subsequent anti-TNFα (either infliximab or adalimumab) is conflicting. We aimed to assess the risk of consecutive immunogenicity to anti-TNFα in a large cohort of patients. METHODS This was a multicenter retrospective study. Medical records of adult and pediatric IBD switchers who had pharmacokinetic data for both agents between 2014 and 2020 were retrieved. Data including age, sex, disease type, duration of therapies, and concomitant use of immunomodulators (IMMs) were recorded. RESULTS Overall, 164 patients were included [52% female; 88% Crohn's disease; mean age = 24.4 ± 14.6 years; 108 (66%) switched from infliximab to adalimumab and 56 (34%) vice versa]; 120 (73.1%) patients switched due to an immunogenic failure. Among patients switching therapy from infliximab to adalimumab due to an immunogenic failure immunogenicity to infliximab was significantly associated with consecutive immunogenicity to adalimumab (p = 0.026). Forthy four out of 120 patients (36.6%) with an immunogenic failure to the first anti-TNFα started an IMM with the second anti-TNFα. This combination with IMM was not associated with reduction of consecutive immunogenicity (p = 0.31), but it was associated with longer drug retention (p = 0.007). Multivariate analysis demonstrated that older age at second anti-TNFα, adjusted to the chronology of therapy and sex, was associated with increased immunogenicity to the second anti-TNFα. CONCLUSION Patients with IBD who switch from infliximab to adalimumab following an immunogenic failure are at increased risk for consecutive immunogenicity to adalimumab. IMM use after a switch prolongs drug retention.
Collapse
Affiliation(s)
| | - Bella Ungar
- Department of Gastroenterology, Sheba Medical Center, Ramat Gan, IsraelThe Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Ramat Gan, IsraelThe Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tali Sharar Fischler
- Division of Gastroenterology, Department of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Irit Avni Biron
- Division of Gastroenterology, Department of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jacob E. Ollech
- Division of Gastroenterology, Department of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Idan Goren
- Division of Gastroenterology, Department of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Manar Matar
- The Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children’s Hospital, Petah Tikva, Israel
| | - Tsachi Tsadok Perets
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel; Adelson School of Medicine, Ariel University, Ariel, Israel
| | - Raanan Shamir
- The Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children’s Hospital, Petah Tikva, IsraelThe Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Iris Dotan
- Division of Gastroenterology, Department of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | | |
Collapse
|
21
|
Fousekis FS, Papamichael K, Kourtis G, Albani EN, Orfanidou A, Saridi M, Katsanos KH, Christodoulou DK. The efficacy of immunomodulators in the prevention and suppression of anti-drug antibodies to anti-tumor necrosis factor therapy in inflammatory bowel disease. Ann Gastroenterol 2022; 35:1-7. [PMID: 34987282 PMCID: PMC8713338 DOI: 10.20524/aog.2021.0682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 10/28/2021] [Indexed: 11/11/2022] Open
Abstract
The development of biological agents against tumor necrosis factor (TNF) has revolutionized the management of inflammatory bowel disease (IBD), frequently achieving induction and maintenance of remission in both ulcerative colitis and Crohn's disease. However, a loss of response due to the development of anti-drug antibodies (ADA) is seen annually in approximately 20% of IBD patients receiving anti-TNF therapy. Current evidence suggests that the use of immunomodulators (IMM), such as thiopurines (azathioprine and 6-mercaptopurine) or methotrexate, may prevent or suppress ADA formation. In this article, we present a comprehensive review of the available literature regarding the efficacy of IMM in the prevention and suppression of ADA development to anti-TNF therapy in patients with IBD.
Collapse
Affiliation(s)
- Fotios S. Fousekis
- Department of Gastroenterology, School of Health Sciences, University Hospital of Ioannina, Faculty of Medicine, University of Ioannina, Ioannina, Greece (Fotios S. Fousekis, Konstantinos H. Katsanos, Dimitrios K. Christodoulou)
| | - Konstantinos Papamichael
- Center for Inflammatory Bowel Diseases, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA (Konstantinos Papamichael)
| | - Georgios Kourtis
- Department of Department of Nursing, “Sotiria” General Hospital, Athens, Greece (Georgios Kourtis)
| | - Eleni N. Albani
- Department of Nursing, University of Patra, Patra, Greece (Eleni N. Albani)
| | - Afroditi Orfanidou
- Academic Department of Gastroenterology, Laiko General Hospital, Medical School of National Kapodistrian University of Athens, Greece (Afroditi Orfanidou)
| | - Maria Saridi
- Department of Nursing, University of Thessaly, Lamia, Greece (Maria Saridi)
| | - Konstantinos H. Katsanos
- Department of Gastroenterology, School of Health Sciences, University Hospital of Ioannina, Faculty of Medicine, University of Ioannina, Ioannina, Greece (Fotios S. Fousekis, Konstantinos H. Katsanos, Dimitrios K. Christodoulou)
| | - Dimitrios K. Christodoulou
- Department of Gastroenterology, School of Health Sciences, University Hospital of Ioannina, Faculty of Medicine, University of Ioannina, Ioannina, Greece (Fotios S. Fousekis, Konstantinos H. Katsanos, Dimitrios K. Christodoulou)
| |
Collapse
|
22
|
Vultaggio A, Perlato M, Nencini F, Vivarelli E, Maggi E, Matucci A. How to Prevent and Mitigate Hypersensitivity Reactions to Biologicals Induced by Anti-Drug Antibodies? Front Immunol 2021; 12:765747. [PMID: 34790200 PMCID: PMC8591239 DOI: 10.3389/fimmu.2021.765747] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 10/13/2021] [Indexed: 01/06/2023] Open
Abstract
Biologicals are widely used therapeutic agents for rheumatologic diseases, cancers, and other chronic inflammatory diseases. They are characterized by complex structures and content of variable amounts of foreign regions, which may lead to anti-drug antibodies (ADA) development. ADA onset may limit the clinical usage of biologicals because they may decrease their safety. In fact they are mainly associated with immediate hypersensitivity reactions (HSRs). Development of ADAs is reduced by concomitant immunosuppressive treatment, while it is increased by longer intervals between drug administrations; thus, regular infusion regimens should be preferred to reduce HSRs. Once ADAs have formed, some procedures can be implemented to reduce the risk of HSRs. ADAs may belong to different isotype; the detection of IgE ADA is advisable to be assessed when high and early ADAs are detected, in order to reduce the risk of severe HRs. In patients who need to reintroduce the biological culprit, as alternative therapies are not available, drug desensitization (DD) may be applied. Desensitization should be conceptually dedicated to patients with an IgE-mediated HSR; however, it can be performed also in patients who had developed non-IgE-mediated HSRs. Although the underlying mechanisms behind successful DD has not been fully clarified, the DD procedure is associated with the inhibition of mast cell degranulation and cytokine production. Additionally, some data are emerging about the inhibition of drug-specific immune responses during DD.
Collapse
Affiliation(s)
| | - Margherita Perlato
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Francesca Nencini
- Immunoallergology Unit, Careggi University Hospital, Florence, Italy
| | | | - Enrico Maggi
- Translational Immunology Unit, Immunology Area, Pediatric Hospital Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico (IRCSS), Rome, Italy
| | - Andrea Matucci
- Immunoallergology Unit, Careggi University Hospital, Florence, Italy
| |
Collapse
|
23
|
Zeng-Wang YM, Cares K, Thomas R, El-Baba M. The Effectiveness of Methylprednisolone as a Premedication Among the Pediatric Population for Preventing Infusion-Related Reactions to Infliximab. Gastroenterol Nurs 2021; 44:449-454. [PMID: 34690297 DOI: 10.1097/sga.0000000000000592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 01/13/2021] [Indexed: 11/25/2022] Open
Abstract
Administering medications prior to infliximab infusions to prevent infusion-related infliximab reactions is a common practice in the United States. However, the premedication protocol varies among different institutions. The purpose of this study was to demonstrate whether the use of methylprednisolone was effective as a premedication to prevent infusion reactions while infliximab was administered to children with inflammatory bowel disease. The effect of concurrent use of other immunomodulators on the rate of reaction incidents was also studied. This was a retrospective chart review, assessing children younger than 21 years diagnosed with inflammatory bowel disease from January 2008 to April 2018. The incident rate of infusion reactions was also compared between two cohorts: those who received the premedication of methylprednisolone and those who did not. Subgroup analysis of concomitant immunomodulators, infliximab dose and frequency, and anti-infliximab assay were also performed. A total of 34 subjects received methylprednisolone as a premedication and 151 subjects did not. No statistically significant difference of allergic reactions was found between the two groups (p = .727). Concomitant immunomodulator therapy lowered the likelihood of developing reactions (p = .048). This study was conducted to help pediatric gastroenterology and infusion nurses better understand and implement evidence-based approaches in the premedication protocol for infusions of anti-tumor necrosis factor-α (anti-TNF-α) antibody products.
Collapse
Affiliation(s)
- Yiping Maggie Zeng-Wang
- Yiping Maggie Zeng-Wang, MSN, FNP-BC, is Nurse Practitioner, Children's Hospital of Michigan, Detroit Medical Center, Detroit
- Kristen Cares, MD, is Pediatrician/Assistant Professor, Children's Hospital of Michigan, Detroit Medical Center, Detroit
- Ronald Thomas, PhD, is Statistician, Children's Hospital of Michigan, Detroit Medical Center, Detroit
- Mohammad El-Baba, MD, is Pediatrician/Professor, Children's Hospital of Michigan, Detroit Medical Center, Detroit
| | - Kristen Cares
- Yiping Maggie Zeng-Wang, MSN, FNP-BC, is Nurse Practitioner, Children's Hospital of Michigan, Detroit Medical Center, Detroit
- Kristen Cares, MD, is Pediatrician/Assistant Professor, Children's Hospital of Michigan, Detroit Medical Center, Detroit
- Ronald Thomas, PhD, is Statistician, Children's Hospital of Michigan, Detroit Medical Center, Detroit
- Mohammad El-Baba, MD, is Pediatrician/Professor, Children's Hospital of Michigan, Detroit Medical Center, Detroit
| | - Ronald Thomas
- Yiping Maggie Zeng-Wang, MSN, FNP-BC, is Nurse Practitioner, Children's Hospital of Michigan, Detroit Medical Center, Detroit
- Kristen Cares, MD, is Pediatrician/Assistant Professor, Children's Hospital of Michigan, Detroit Medical Center, Detroit
- Ronald Thomas, PhD, is Statistician, Children's Hospital of Michigan, Detroit Medical Center, Detroit
- Mohammad El-Baba, MD, is Pediatrician/Professor, Children's Hospital of Michigan, Detroit Medical Center, Detroit
| | - Mohammad El-Baba
- Yiping Maggie Zeng-Wang, MSN, FNP-BC, is Nurse Practitioner, Children's Hospital of Michigan, Detroit Medical Center, Detroit
- Kristen Cares, MD, is Pediatrician/Assistant Professor, Children's Hospital of Michigan, Detroit Medical Center, Detroit
- Ronald Thomas, PhD, is Statistician, Children's Hospital of Michigan, Detroit Medical Center, Detroit
- Mohammad El-Baba, MD, is Pediatrician/Professor, Children's Hospital of Michigan, Detroit Medical Center, Detroit
| |
Collapse
|
24
|
Raine T, Verstockt B, Kopylov U, Karmiris K, Goldberg R, Atreya R, Burisch J, Burke J, Ellul P, Hedin C, Holubar SD, Katsanos K, Lobaton T, Schmidt C, Cullen G. ECCO Topical Review: Refractory Inflammatory Bowel Disease. J Crohns Colitis 2021; 15:1605-1620. [PMID: 34160593 DOI: 10.1093/ecco-jcc/jjab112] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Inflammatory bowel disease is a chronic disease with variable degrees of extent, severity, and activity. A proportion of patients will have disease that is refractory to licensed therapies, resulting in significant impairment in quality of life. The treatment of these patients involves a systematic approach by the entire multidisciplinary team, with particular consideration given to medical options including unlicensed therapies, surgical interventions, and dietetic and psychological support. The purpose of this review is to guide clinicians through this process and provide an accurate summary of the available evidence for different strategies.
Collapse
Affiliation(s)
- Tim Raine
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
- Department of Chronic Diseases and Metabolism, TARGID - IBD, KU Leuven, Leuven, Belgium
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Ramat Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | | | - Rimma Goldberg
- Department of Gastroenterology, Monash Health and School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Raja Atreya
- Department of Medicine 1, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Johan Burisch
- Gastrounit, Medical Division, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - John Burke
- Colorectal and General Surgery, Beaumont Hospital, Dublin, Ireland
| | - Pierre Ellul
- Department of Medicine, Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | - Charlotte Hedin
- Karolinska Institutet, Department of Medicine Solna, Stockholm, Sweden
- Karolinska University Hospital, Gastroenterology Unit, Department of Gastroenterology, Dermatovenereology and Rheumatology, Stockholm, Sweden
| | - Stefan D Holubar
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, University and Medical School of Ioannina, Ioannina, Greece
| | - Triana Lobaton
- Department of Gastroenterology, Ghent University Hospital, Ghent, Belgium
| | - Carsten Schmidt
- Medical Faculty of the Friedrich Schiller University, Jena, Germany
| | - Garret Cullen
- Centre for Colorectal Disease, St Vincent's University Hospital and School of Medicine, University College Dublin, Gastroenterology, Dublin, Ireland
| |
Collapse
|
25
|
Cheifetz AS, Abreu MT, Afif W, Cross RK, Dubinsky MC, Loftus EV Jr, Osterman MT, Saroufim A, Siegel CA, Yarur AJ, Melmed GY, Papamichael K. A Comprehensive Literature Review and Expert Consensus Statement on Therapeutic Drug Monitoring of Biologics in Inflammatory Bowel Disease. Am J Gastroenterol 2021; 116:2014-25. [PMID: 34388143 DOI: 10.14309/ajg.0000000000001396] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 07/14/2021] [Indexed: 12/11/2022]
Abstract
Therapeutic drug monitoring (TDM) of biologics is a rapidly evolving field. We aimed to provide a consensus statement regarding the clinical utility of TDM for biologics in inflammatory bowel disease (IBD). A modified Delphi method was applied to develop consensus statements. A comprehensive literature review was performed regarding TDM of biologic therapies in IBD, and 45 statements were subsequently formulated on the potential application of TDM in IBD. The statements, along with literature, were then presented to a panel of 10 gastroenterologists with expertise in IBD and TDM who anonymously rated them on a scale of 1-10 (1 = strongly disagree and 10 = strongly agree). An expert consensus development meeting was held virtually to review, discuss, refine, and reformulate statements that did not meet criteria for agreement or that were ambiguous. During the meeting, additional statements were proposed. Panelists then confidentially revoted, and statements rated ≥7 by 80% or more of the participants were accepted. During the virtual meeting, 8 statements were reworded, 7 new statements were proposed, and 19 statements were rerated. Consensus was finally reached in 48/49 statements. The panel agreed that reactive TDM should be used for all biologics for both primary nonresponse and secondary loss of response. It was recommended that treatment discontinuation should not be considered for infliximab or adalimumab until a drug concentration of at least 10-15 μg/mL was achieved. Consensus was also achieved regarding the utility of proactive TDM for anti-tumor necrosis factor therapy. It was recommended to perform proactive TDM after induction and at least once during maintenance. Consensus was achieved in most cases regarding the utility of TDM of biologics in IBD, specifically for reactive and proactive TDM of anti-tumor necrosis factors.
Collapse
|
26
|
Battat R, Lukin D, Scherl EJ, Pola S, Kumar A, Okada L, Yang L, Jain A, Siegel CA. Immunogenicity of Tumor Necrosis Factor Antagonists and Effect of Dose Escalation on Anti-Drug Antibodies and Serum Drug Concentrations in Inflammatory Bowel Disease. Inflamm Bowel Dis 2021; 27:1443-1451. [PMID: 33252119 DOI: 10.1093/ibd/izaa313] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Infliximab and adalimumab concentrations are associated with important outcomes in inflammatory bowel disease (IBD). Antibodies to infliximab (ATI) and adalimumab (ATA) are associated with reduced drug concentrations and worse outcomes. Because the efficacy of dose escalation to overcome antibodies is unclear, we assessed the impact of this strategy to overcome immunogenicity in IBD. METHODS Infliximab and adalimumab dosing, drug, and antibody concentrations were extracted from a database of patients with IBD having specimens collected for therapeutic drug monitoring. The primary outcome compared proportions with either infliximab ≥5 μg/mL or adalimumab ≥7.5 μg/mL and undetectable antibodies between dose-escalated and non-escalated patients. Area under the receiver operating characteristic curve analyses determined antibody concentrations below which dose escalation was associated with the primary outcome. RESULTS The study included 63,176 patients treated with infliximab and 46,429 patients treated with adalimumab. We detected ATI and ATA in 23.6% (n = 14,900) of patients treated with infliximab and 19.6% (n = 9101) of patients treated with adalimumab. In patients with ATI, infliximab dose escalation (n = 453) yielded higher proportions achieving the primary outcome (47.5% vs 30.9%; P < 0.001), greater drug concentration increases (5.9 μg/mL vs 0.2 μg/mL; P < 0.001), and ATI reductions (4.3 U/mL vs 1.9 U/mL; P = 0.002) compared to no escalation (n = 204). An ATI threshold of 8.55 U/mL was associated with achieving the primary outcome with dose escalation (area under the curve = 0.66). For patients with ATI ≤8.55 U/mL (n = 274), higher proportions (59.1% vs 29.6%; P < 0.001) achieved the primary outcome compared with those with ATI >8.55 U/mL (n = 179). No patients treated with adalimumab achieved the primary outcome (0/390), regardless of dose escalation (n = 87). CONCLUSION Dose escalation increased drug concentrations and eliminated antibodies with infliximab but not adalimumab. Initial ATI ≤8.55 U/mL was associated with increased efficacy of dose escalation using this assay.
Collapse
Affiliation(s)
- Robert Battat
- Jill Roberts Center for IBD, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Dana Lukin
- Jill Roberts Center for IBD, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Ellen J Scherl
- Jill Roberts Center for IBD, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Suresh Pola
- Kaiser Permanente San Diego, San Diego, California, USA
| | - Anand Kumar
- Jill Roberts Center for IBD, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Lauren Okada
- Prometheus Biosciences, San Diego, California, USA
| | - Lei Yang
- Prometheus Biosciences, San Diego, California, USA
| | - Anjali Jain
- Prometheus Biosciences, San Diego, California, USA
| | - Corey A Siegel
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| |
Collapse
|
27
|
Privitera G, Pugliese D, Onali S, Petito V, Scaldaferri F, Gasbarrini A, Danese S, Armuzzi A. Combination therapy in inflammatory bowel disease - from traditional immunosuppressors towards the new paradigm of dual targeted therapy. Autoimmun Rev 2021; 20:102832. [PMID: 33866066 DOI: 10.1016/j.autrev.2021.102832] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 02/15/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Combining immunosuppressors has been proposed as a strategy to enhance treatment efficacy in Inflammatory Bowel Disease (IBD). AIM To summarize current evidence on combinations of targeted therapies with traditional immunosuppressors or with other targeted therapies. METHODS A literature search on PubMed and Medline databases was performed to identify relevant articles. RESULTS Current evidence supports that the combination of infliximab and thiopurines is more effective than monotherapy with both agents in inducing remission in Crohn's Disease and Ulcerative colitis. Data on other combinations of other biologics and traditional immunosuppressors is lacking or show conflicting results. Vedolizumab seems a potentially effective maintenance regimen after calcineurin inhibitors-based rescue therapy in acute severe ulcerative colitis, as an alternative to thiopurines. Dual Targeted Therapy, which is the combination of 2 targeted therapies, might be a reasonable choice in patients with concomitant IBD and extraintestinal manifestations, or in patients with medical-refractory IBD who lack valid alternatives. Combinations with thiopurines are associated with an increased risk of infections and lymphoma. Data on other combinations is scarcer, but no specific safety issue has emerged so far. CONCLUSIONS Combination therapies seem to be effective in selected patients, with an overall acceptable safety profile.
Collapse
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.
| | - Sara Onali
- Gastroenterology Unit, University Hospital of Cagliari, Department of Science and Public Health, University of Cagliari, Italy
| | - Valentina Petito
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, 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.
| | - 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.
| | - Silvio Danese
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center, Istituto di Ricovero e Cura a Carattere Scientifico, Rozzano, Milan 20089, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.
| | - Alessandro Armuzzi
- 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.
| |
Collapse
|
28
|
Borrega R, Araújo C, Aguiam N, Magro F, Fonseca JE, Danese S, Lopes J, Goncalves J. Systematic Review and Principal Components Analysis of the Immunogenicity of Adalimumab. BioDrugs 2021; 35:35-45. [PMID: 33301077 DOI: 10.1007/s40259-020-00458-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND The reported immunogenicity rates of adalimumab differ significantly between studies because of a wide variety of factors related to the disease, patients, study design, and products. OBJECTIVE The objective of this study was to characterize this variability and identify the major factors that contribute to these fluctuations. METHODS A systematic literature review was conducted using the MEDLINE, Clinicaltrials.gov, and Cochrane Library databases. Studies that reported the immunogenicity rates of adalimumab were selected, and data pertaining to publication details, study characteristics, characteristics of the cohort at baseline, and immunogenicity were extracted. Records were sorted according to the immunogenicity assay type, and mean immunogenicity values for each assay type were calculated. Normalised immunogenicity was calculated for each report by subtracting the appropriate mean immunogenicity value. Collected data were subjected to statistical analysis, namely analysis of variance (ANOVA) and principal component analysis, to unveil immunogenicity rate patterns across studies from a multivariate perspective. RESULTS In total, 130 publications were identified, from which 165 data records were extracted and included in the analysis. The immunogenicity rates of adalimumab averaged 24.9% across studies and varied significantly over time, ranging between 0 and 87%. An increase across time in the reported immunogenicity rates was detected, and the assay used to detect anti-adalimumab antibodies was a significant (but not exclusive) contributor to this trend. Furthermore, the principal components analysis revealed that the type of study and the exposure time were associated with the assay-normalised immunogenicity rates of adalimumab. Nonetheless, neither these nor the remaining factors included in this analysis seem to contribute to the temporal increase in reported immunogenicity rates. CONCLUSIONS Future studies that evaluate the patient-, product-, and disease-related factors behind the immunogenicity of adalimumab are required because the evidence published so far does not completely explain the temporal increase in immunogenicity rates detected in this analysis.
Collapse
|
29
|
Abdalla T, Mansour M, Bouazzi D, Lowes MA, Jemec GBE, Alavi A. Therapeutic Drug Monitoring in Patients with Suboptimal Response to Adalimumab for Hidradenitis Suppurativa: A Retrospective Case Series. Am J Clin Dermatol 2021; 22:275-283. [PMID: 33242185 DOI: 10.1007/s40257-020-00575-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Adalimumab, a tumor necrosis factor-α inhibitor, is a biologic used for the treatment of moderate-to-severe hidradenitis suppurativa (HS). It is well known that patients may experience loss of efficacy from its use in other conditions, and it is suggested that developing a strategy for therapeutic drug monitoring (TDM) may help secure optimal clinical outcomes. OBJECTIVES We sought to determine serum adalimumab concentrations and anti-adalimumab antibody (AAA) status in patients with moderate-to-severe HS. METHODS A retrospective case series of 38 patients with suboptimal response to adalimumab 40 mg weekly was conducted at a community dermatology clinic. Adalimumab serum trough levels, AAA status, and inflammatory biomarkers were collected. Blood was drawn on identification of suboptimal response (after a minimum of 12 weeks) and was collected once prior to receiving the next scheduled dose. Kruskal-Wallis and Chi-squared tests were used for data analysis. RESULTS A total of 38 patients had a median adalimumab trough concentration of 8.76 (interquartile range [IQR] 1.3-12.5) µg/mL. The median duration of adalimumab therapy of all patients was 21 (IQR 12-24) months. AAAs were detected in nine patients (24%), and all had subtherapeutic serum concentrations (< 6 µg/mL). Patients who were AAA+ had a significantly lower median adalimumab concentration than those who were AAA- (0.02 µg/mL [range 0.02-0.81] vs. 10.14 [range 0.76-48.00]; p = 0.0006). CONCLUSION Patients with AAAs had significantly lower serum adalimumab levels. The current study suggests that TDM may identify underlying reasons for suboptimal response and detect patients who may benefit from dose optimization strategies.
Collapse
Affiliation(s)
- Tasnim Abdalla
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Mark Mansour
- Schulich School of Medicine & Dentistry, Western University, London, Canada
| | - Dorra Bouazzi
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Dermatology, Zealand University Hospital, Roskilde, Denmark
- Health Sciences Faculty, University of Copenhagen, Copenhagen, Denmark
| | | | - Gregor B E Jemec
- Department of Dermatology, Zealand University Hospital, Roskilde, Denmark
- Health Sciences Faculty, University of Copenhagen, Copenhagen, Denmark
| | - Afsaneh Alavi
- Faculty of Medicine, University of Toronto, Toronto, Canada.
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
30
|
Almon E, Shaaltiel Y, Sbeit W, Fich A, Schwartz D, Waterman M, Szlaifer M, Reuveni H, Amit-Cohen BC, Alon S, Chertkoff R, Paz A, Ilan Y. Novel Orally Administered Recombinant Anti-TNF Alpha Fusion Protein for the Treatment of Ulcerative Colitis: Results From a Phase 2a Clinical Trial. J Clin Gastroenterol 2021; 55:134-140. [PMID: 32501868 PMCID: PMC7803480 DOI: 10.1097/mcg.0000000000001314] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 12/23/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND OBJECTIVE OPRX-106 is an orally administered BY2 plant cell-expressing recombinant TNF fusion protein (TNFR). Oral administration of OPRX-106 was shown to be safe and effective in inducing favorable anti-inflammatory immune modulation in humans. The current study was aimed at determining the safety and efficacy of OPRX-106 in patients with ulcerative colitis (UC). METHODS Twenty-five patients with active mild-to-moderate UC were enrolled in an open-label trial. Patients were randomized to receive 2 or 8 mg of OPRX-106 administered orally once daily, for 8 weeks. Patients were monitored for safety and efficacy including clinical response or clinical remission, based on the Mayo score. The histopathological improvement in Geboes score, calprotectin level and hs-CRP, and exploratory immune parameters by means of fluorescence-activated cell sorting and cytokine levels were monitored. RESULTS Oral administration of OPRX-106 was found to be safe and well tolerated without absorption into the circulation. Out of 24 patients, 18 completed the trial. The analysis of the patients completing treatment demonstrated clinical efficacy as measured by clinical response or remission in 67% and 28%, respectively. Reduction in calprotectin levels and improved Geboes score were noted in the majority of the treated patients. The beneficial clinical effect was associated with an increase in a CD4+CD25+FoxP3 subset of suppressor lymphocytes and a reduction in interleukin 6 and interferon gamma serum levels. CONCLUSIONS Oral administration of the nonabsorbable OPRX-106 is safe and effective in mild-to-moderate UC, and not associated with immune suppression, while inducing favorable anti-inflammatory immune modulation.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Yaron Ilan
- Hadassah Medical Center, Jerusalem, Israel
| |
Collapse
|
31
|
Abstract
Five biologics are approved for the treatment of ulcerative colitis (UC): infliximab, adalimumab, golimumab, vedolizumab, and ustekinumab. These drugs have varying levels of efficacy and are recommended as first-line treatment of moderate to severe UC. There has been only 1 head-to-head trial comparing the efficacy of the biologics, adalimumab and vedolizumab, which has important implications for management. Therapeutic drug monitoring of biologics, especially anti-TNF alpha agents, may improve the long-term efficacy of these agents. The future of treatment may include personalization of medications, based on patient-specific and disease-specific characteristics as well as biomarkers, along with appropriate therapeutic drug monitoring.
Collapse
|
32
|
Kucharzik T, Dignass AU, Atreya R, Bokemeyer B, Esters P, Herrlinger K, Kannengießer K, Kienle P, Langhorst J, Lügering A, Schreiber S, Stallmach A, Stein J, Sturm A, Teich N, Siegmund B. Aktualisierte S3-Leitlinie Colitis ulcerosa – Living Guideline. Z Gastroenterol 2020; 58:e241-e326. [PMID: 33260237 DOI: 10.1055/a-1296-3444] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Torsten Kucharzik
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Klinikum Lüneburg, Lüneburg, Deutschland
| | - Axel U Dignass
- Medizinische Klinik I, Agaplesion Markus Krankenhaus, Frankfurt am Main, Deutschland
| | - Raja Atreya
- Medizinische Klinik 1, Universitätsklinikum Erlangen, Deutschland
| | - Bernd Bokemeyer
- Gastroenterologische Gemeinschaftspraxis Minden, Deutschland
| | - Philip Esters
- Medizinische Klinik I, Agaplesion Markus Krankenhaus, Frankfurt am Main, Deutschland
| | | | - Klaus Kannengießer
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Klinikum Lüneburg, Lüneburg, Deutschland
| | - Peter Kienle
- Allgemein- und Viszeralchirurgie, Theresienkrankenhaus und Sankt Hedwig-Klinik GmbH, Mannheim, Deutschland
| | - Jost Langhorst
- Klinik für Integrative Medizin und Naturheilkunde, Klinikum am Bruderwald, Bamberg, Deutschland
| | - Andreas Lügering
- Medizinisches Versorgungszentrum Portal 10, Münster, Deutschland
| | | | - Andreas Stallmach
- Gastroenterologie, Hepatologie und Infektiologie, Friedrich Schiller Universität, Jena, Deutschland
| | - Jürgen Stein
- Innere Medizin mit Schwerpunkt Gastroenterologie, Krankenhaus Sachsenhausen, Frankfurt/Main, Deutschland
| | - Andreas Sturm
- Klinik für Innere Medizin mit Schwerpunkt Gastroenterologie, DRK Kliniken Berlin Westend, Berlin, Deutschland
| | - Niels Teich
- Internistische Gemeinschaftspraxis für Verdauungs- und Stoffwechselkrankheiten, Leipzig, Deutschland
| | - Britta Siegmund
- Medizinische Klinik I, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Deutschland
| | | |
Collapse
|
33
|
Affiliation(s)
- Torsten Kucharzik
- Klinikum Lüneburg, Klinik für Allgemeine Innere Medizin und Gastroenterologie, Lüneburg
| | - Axel Dignaß
- Medizinische Klinik 1, Agaplesion Markus Krankenhaus, Frankfurt/Main, Frankfurt am Main
| | - Britta Siegmund
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Berlin, Germany
| |
Collapse
|
34
|
Liefferinckx C, Cremer A, Franchimont D. Switching biologics used in inflammatory bowel diseases: how to deal with in practice? Curr Opin Pharmacol 2020; 55:82-89. [PMID: 33166871 DOI: 10.1016/j.coph.2020.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 10/04/2020] [Accepted: 10/05/2020] [Indexed: 12/28/2022]
Abstract
Inflammatory bowel disease patients do not all respond to biological treatment since several patients will initially respond but will lose response or develop side effects over time. In such cases, a switch from one biologic to another offers a valuable clinical solution. This requires to evaluate both patient and drug profiles in combination with the reason(s) for switching in order to adequately select the second-line biologic. Therapeutic drug monitoring is obviously a useful tool but is currently limited to the use of anti-TNFα. In this review paper, we provide overview and guidance on switching biologics in clinical practice, with the emphasis on the motivations for switching, the selection of the second-line biologic, as well as explanations on how and when to switch.
Collapse
Affiliation(s)
- Claire Liefferinckx
- Department of Gastroenterology, Erasme Hospital, ULB, Brussels, Belgium; Laboratory of Experimental Gastroenterology, ULB, Brussels, Belgium.
| | - Anneline Cremer
- Department of Gastroenterology, Erasme Hospital, ULB, Brussels, Belgium; Laboratory of Experimental Gastroenterology, ULB, Brussels, Belgium
| | - Denis Franchimont
- Department of Gastroenterology, Erasme Hospital, ULB, Brussels, Belgium; Laboratory of Experimental Gastroenterology, ULB, Brussels, Belgium
| |
Collapse
|
35
|
Caenepeel C, Sadat Seyed Tabib N, Vieira-Silva S, Vermeire S. Review article: how the intestinal microbiota may reflect disease activity and influence therapeutic outcome in inflammatory bowel disease. Aliment Pharmacol Ther 2020; 52:1453-1468. [PMID: 32969507 DOI: 10.1111/apt.16096] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 02/08/2020] [Accepted: 09/03/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Intestinal bacteria produce metabolites and by-products necessary for homeostasis. Imbalance in this equilibrium is linked to multiple pathologies including inflammatory bowel disease (IBD). The role of the gut microbiota in determining treatment response is becoming apparent, and may act as biomarker for efficacy. AIM To describe knowledge about the intestinal microbiota on disease severity and treatment outcomes in IBD METHODS: Descriptive review using PubMed to identify literature on the intestinal microbiota in IBD RESULTS: Severe IBD has a less diverse microbiota with fewer commensal microbiota communities and more opportunistic pathogenic bacteria originating from the oral cavity or respiratory tract. IBD treatments can alter gut microbiota composition, but in vitro/in vivo studies are needed to prove causation. A diversification of the microbiota is observed during remission. Patients with a more diverse baseline microbiome and higher microbial diversity show better response to anti-tumour necrosis factor-α, vedolizumab and ustekinumab therapy. Higher abundance of short chain fatty acid-producing bacteria, fewer mucus-colonising bacteria and lower abundance of pro-inflammatory bacteria have also been associated with a favourable outcome. Predictive models, based on a combination of microbiota, clinical data and serological markers, have good accuracy for treatment outcome and disease severity. CONCLUSION The intestinal microbiota in IBD carries a set of promising biomarkers of disease activity and prediction of therapeutic outcome. Current insights may also help in designing microbiota modulation strategies to improve outcomes in IBD.
Collapse
Affiliation(s)
| | | | - Sara Vieira-Silva
- Department of Microbiology and Immunology, Laboratory of Molecular Bacteriology, Rega Institute for Medical Research, VIB, KU Leuven, Leuven, Belgium
| | - Séverine Vermeire
- Department of Chronic Diseases & Metabolism, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium.,Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
36
|
Matar M, Shamir R, Turner D, Broide E, Weiss B, Ledder O, Guz-Mark A, Rinawi F, Cohen S, Topf-Olivestone C, Shaoul R, Yerushalmi B, Ben-Horin S, Assa A. Combination Therapy of Adalimumab With an Immunomodulator Is Not More Effective Than Adalimumab Monotherapy in Children With Crohn's Disease: A Post Hoc Analysis of the PAILOT Randomized Controlled Trial. Inflamm Bowel Dis 2020; 26:1627-1635. [PMID: 31793630 DOI: 10.1093/ibd/izz294] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND The PAILOT trial was a randomized controlled trial aimed to evaluate proactive vs reactive therapeutic drug monitoring in children with Crohn's disease (CD) treated with adalimumab. Our aim in this post hoc analysis of the PAILOT trial was to assess the efficacy and safety of adalimumab combination treatment in comparison with monotherapy at week 72 after adalimumab induction. METHODS Participants were children 6-17 years old, biologic naïve, with moderate to severe CD, who responded to adalimumab induction at week 4. Patients receiving immunomodulators at baseline maintained a stable dose until week 24; patients could then discontinue immunomodulators. At each visit, patients were assessed for disease index, serum biomarkers, fecal calprotectin, adalimumab trough concentration, and anti-adalimumab antibodies. RESULTS Out of the 78 patients (29% female; mean age, 14.3 ± 2.6 years), 34 patients (44%) received combination therapy. During the study period, there was no significant difference in the rates of sustained corticosteroid-free clinical remission (25/34, 73%, vs 28/44, 63%; P = 0.35) or sustained composite outcome of clinical remission, C-reactive protein ≤0.5 mg/dL, and calprotectin ≤150 µg/g (10/34, 29%, vs 14/44, 32%; P = 0.77) between the combination group and the monotherapy group, respectively. Clinical and biological outcomes did not differ between the proactive and reactive subgroups within the combination and monotherapy groups. Adalimumab trough concentrations and immunogenicity were not significantly different between groups. The rate of serious adverse events was not significantly different between groups but was numerically higher in the monotherapy group. CONCLUSIONS Combination therapy of adalimumab and an immunomodulator was not more effective than adalimumab monotherapy in children with CD (ClinicalTrials.gov No. NCT02256462).
Collapse
Affiliation(s)
- Manar Matar
- The Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Hospital, Petach-Tikva, Israel
| | - Raanan Shamir
- The Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Hospital, Petach-Tikva, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dan Turner
- The Juliet Keidan Institute of Pediatric Gastroenterology, Nutrition, Shaare Zedek Medical Center, The Hebrew University, Jerusalem, Israel
| | - Efrat Broide
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Gastroenterology Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Batia Weiss
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Gastroenterology Unit, Sheba Medical Center, Edmond and Lily Safra Childen's Hospital, Ramat-Gan, Tel-Hashomer, Israel
| | - Oren Ledder
- The Juliet Keidan Institute of Pediatric Gastroenterology, Nutrition, Shaare Zedek Medical Center, The Hebrew University, Jerusalem, Israel
| | - Anat Guz-Mark
- The Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Hospital, Petach-Tikva, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Firas Rinawi
- The Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Hospital, Petach-Tikva, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shlomi Cohen
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Gastroenterology Unit, "Dana-Dwek" Children's Hospital, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
| | | | - Ron Shaoul
- Pediatric Gastroenterology Unit, Rambam Medical Center, Haifa, Israel
| | - Baruch Yerushalmi
- Pediatric Gastroenterology Unit, Saban Pediatric Medical Center, Soroka University Hospital and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Shomron Ben-Horin
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Gastroenterology, Sheba Medical Center, Ramat-Gan, Tel-Hashomer, Israel
| | - Amit Assa
- The Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Hospital, Petach-Tikva, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
37
|
Nakase H, Matsumoto T, Watanabe K, Hisamatsu T. The shining DIAMOND for evidence-based treatment strategies for Crohn's disease. J Gastroenterol 2020; 55:824-832. [PMID: 32661927 DOI: 10.1007/s00535-020-01702-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/18/2020] [Indexed: 02/04/2023]
Abstract
Anti-tumor necrosis factor (TNF)-α antibodies are effective therapeutic agents to treat inflammatory bowel disease (IBD). In the biologic era, the development of immunogenicity has been a critical issue for secondary loss of response. The superiority of anti-TNF therapy in combination with immunomodulators (IMs) is well-established for infliximab (IFX) but less evident for adalimumab (ADA). To clarify the contribution of thiopurines to ADA-treated patients with Crohn's disease (CD), the deep remission of immunomodulator and adalimumab combination therapy for Crohn's disease (DIAMOND) studies provided the first randomized comparison of efficacy between ADA monotherapy and ADA with thiopurine. The results of the DIAMOND and DIAMOND2 studies revealed the appropriate ADA therapeutic strategy for immunosuppressant-naïve patients with active CD based on therapeutic drug monitoring, endoscopic findings and clinical issues regarding the use of thiopurines.
Collapse
Affiliation(s)
- Hiroshi Nakase
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, S-1, W-16, Chuoku, Sapporo, Hokkaido, 060-8543, Japan.
| | - Takayuki Matsumoto
- Division of Gastroenterology, Department of Medicine, Iwate Medical University, Morioka, Iwate, Japan
| | - Kenji Watanabe
- Division of Internal Medicine, Center for Inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Tadakazu Hisamatsu
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, Mitaka, Tokyo, Japan
| |
Collapse
|
38
|
Roblin X, Williet N, Boschetti G, Phelip JM, Del Tedesco E, Berger AE, Vedrines P, Duru G, Peyrin-Biroulet L, Nancey S, Flourie B, Paul S. Addition of azathioprine to the switch of anti-TNF in patients with IBD in clinical relapse with undetectable anti-TNF trough levels and antidrug antibodies: a prospective randomised trial. Gut 2020; 69:1206-1212. [PMID: 31980448 DOI: 10.1136/gutjnl-2019-319758] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 01/10/2020] [Accepted: 01/13/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVES In patients with IBD experiencing an immune-mediated loss of response (LOR) to antitumour necrosis factor (anti-TNF), algorithms recommend a switch of anti-TNF without immunosuppressive drug. The aim of our study was to compare in these patients two strategies: either switch to a second anti-TNF alone or with addition of azathioprine (AZA). After randomisation outcomes (time to clinical and pharmacokinetic failure) were compared between the two groups during a 2-year follow-up period. DESIGN Consecutive IBD patients in immune-mediated LOR to a first optimised anti-TNF given in monotherapy were randomised to receive either AZA or nothing with induction by a second anti-TNF in both arms. Clinical failure was defined for Crohn's disease (CD) as a Harvey-Bradshaw index ≥5 associated with a faecal calprotectin level >250 µg/g stool and for UC as a Mayo score >5 with endoscopic subscore >1 or as the occurrence of adverse events requiring to stop treatment. Unfavourable pharmacokinetics of the second anti-TNF were defined by the appearance of undetectable trough levels of anti-TNF with high antibodies (drug-sensitive assay) or by that of antibodies (drug-tolerant assay). RESULTS Ninety patients (48 CDs) were included, and 45 of them received AZA after randomisation. The second anti-TNF was adalimumab or infliximab in 40 and 50 patients, respectively. Rates of clinical failure and occurrence of unfavourable pharmacokinetics were higher in monotherapy compared with combination therapy (p<0.001; median time of clinical failure since randomisation 18 vs >24 months). At 24 months, survival rates without clinical failure and without appearance of unfavourable pharmacokinetics were respectively 22 versus 77% and 22% versus 78% (p<0.001 for both) in monotherapy versus combination therapy. Only the use of combination therapy was associated with favourable outcomes after anti-TNF switch. CONCLUSION In case of immune-mediated LOR to a first anti-TNF, AZA should be associated with the second anti-TNF. TRIAL REGISTRATION NUMBER 03580876.
Collapse
Affiliation(s)
- Xavier Roblin
- Department of Gastroenterology, CHU Saint-Étienne, Saint-Etienne, Rhône-Alpes, France
| | - Nicolas Williet
- Department of Gastroenterology, CHU Saint-Étienne, Saint-Etienne, Rhône-Alpes, France
| | - Gilles Boschetti
- Department of Gastroenterology, Hospital Lyon-South, Pierre-Benite, France
| | - Jean-Marc Phelip
- Department of Gastroenterology, CHU Saint-Étienne, Saint-Etienne, Rhône-Alpes, France
| | - Emilie Del Tedesco
- Department of Gastroenterology, CHU Saint-Étienne, Saint-Etienne, Rhône-Alpes, France
| | - Anne-Emmanuelle Berger
- Department of Immunology, CIC 1408, GIMAP, CHU Saint-Étienne, Saint-Etienne, Rhône-Alpes, France
| | - Philippe Vedrines
- Gastro-enterology Department, Centre Hospitalier du Forez à Montbrison Instituts de Formation, Montbrison, Auvergne-Rhône-Alpes, France
| | - Gerard Duru
- Department of Statistics, UCBL, Villeurbanne, Auvergne-Rhône-Alpes, France
| | - Laurent Peyrin-Biroulet
- Department of gastroenterology, University Hospital Centre Nancy, Nancy, Lorraine, France.,INSERM U954, Nancy 1 University, Nancy, Lorraine, France
| | - Stéphane Nancey
- Department of Gastroenterology, Hospital Lyon-South, Pierre-Benite, France
| | - Bernard Flourie
- Department of Gastroenterology, Hospital Lyon-South, Pierre-Benite, France
| | - Stephane Paul
- Department of Immunology, CIC 1408, GIMAP, CHU Saint-Étienne, Saint-Etienne, Rhône-Alpes, France
| |
Collapse
|
39
|
Colman RJ, Portocarrero-Castillo A, Chona D, Hellmann J, Minar P, Rosen MJ. Favorable Outcomes and Anti-TNF Durability After Addition of an Immunomodulator for Anti-Drug Antibodies in Pediatric IBD Patients. Inflamm Bowel Dis 2020; 27:507-515. [PMID: 32426829 PMCID: PMC7957223 DOI: 10.1093/ibd/izaa108] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Anti-drug antibodies (ADAs) to anti-tumor necrosis factor alpha (anti-TNF) drugs are associated with increased drug clearance and loss of response. We aimed to assess the effectiveness of starting an immunomodulator (IM) drug in patients with newly detected ADAs on anti-TNF monotherapy. METHODS We reviewed the medical records of pediatric patients with inflammatory bowel disease on infliximab or adalimumab monotherapy with first-time detection of significant ADAs between 2014 and 2018. Patients who started an IM within 3 months of ADA detection were compared with those who did not (No-IM). Outcomes included steroid-free clinical and biochemical remission on the same anti-TNF , anti-TNF durability, and ADA reversal. RESULTS We identified 89 patients with ADAs: 30 IM patients and 59 No-IM patients. The initial anti-TNF was stopped shortly after ADA detection in 36% of the No-IM patients vs none of the IM patients, driving longer survival on the initial anti-TNF in the IM group (P = 0.005). At 12 months, steroid-free clinical and biochemical remission on the same anti-TNF occurred in 53.9% of the IM group vs 26.8% in the No-IM group (P = 0.025). Drug levels rose higher (P = 0.003) and ADA levels fell farther (P = 0.037) in the IM group than in the No-IM group. Baseline ADA level predicted ADA reversal in the No-IM patients with an area under the receiver operating characteristic of 0.79 (P = 0.006). An ADA level <329 ng/mL had a 76.2% sensitivity and an 83.3% specificity for ADA reversal without IM. CONCLUSIONS Pediatric patients with inflammatory bowel disease on anti-TNF monotherapy who started an IM for significant ADA levels exhibited longer anti-TNF durability and a higher likelihood of steroid-free clinical and biochemical remission on the same anti-TNF. Patients not treated with an IM were unlikely to reverse ADAs >329 ng/mL.
Collapse
Affiliation(s)
- Ruben J Colman
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United States
| | - Andrea Portocarrero-Castillo
- Division of Gastroenterology, Hepatology and Nutrition, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Deepika Chona
- Division of Gastroenterology, Hepatology and Nutrition, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Jennifer Hellmann
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Phillip Minar
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Michael J Rosen
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
- Address correspondence to: Michael J. Rosen, MD, MSCI, 3333 Burnet Avenue, MLC 2010, Cincinnati, OH 45229 ()
| |
Collapse
|
40
|
Dhindsa BS, Dhaliwal A, Mashiana HS, Saghir SM, Sayles H, Mubder M, Ohning G, Eichele D. Reversal of anti-drug antibodies against tumor necrosis factor inhibitors with addition of immunomodulators: A systematic review and meta-analysis. Indian J Gastroenterol 2020; 39:153-60. [PMID: 32468382 DOI: 10.1007/s12664-020-01031-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 03/24/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND The development of anti-drug antibodies (ADA) to tumor necrosis factor (TNF-α) inhibitors is a significant result contributing to the loss of clinical response in inflammatory bowel disease (IBD). AIMS We performed a systematic review and meta-analysis to assess whether the addition of immunomodulators to TNF-α inhibitors lead to reversal of antibody formation in TNF-α inhibitor-treated IBD patients. METHODS We conducted a comprehensive search of electronic databases from inception through October 2018 in order to identify specific studies describing clinical response in IBD patients following the addition of immunomodulators (methotrexate or thiopurines) to TNF-α inhibitors. Clinical response was expressed as an improvement of symptoms, with a noted decrease or complete elimination of ADA against TNF-α inhibitors. The meta-analysis was performed using the DerSimonian and Laird random-effect model. RESULTS Four studies were included in our final meta-analysis, which reported outcomes in 72 patients receiving TNF-α inhibitors. Forty-nine of the seventy-two (68%) patients received either methotrexate (19) or thiopurines (30). The average follow up period was 13.5 months. The overall pooled clinical response was 73.86% (95% confidence interval [CI] = 47.36-94.38, I2 = 60.77%). CONCLUSION In our meta-analysis, addition of immunomodulators to TNF-α inhibitors was shown to restore the clinical response in 74% of the patients by either decreasing or completely eliminating anti-drug antibody levels. Further long-term multicenter studies are needed to validate these findings.
Collapse
|
41
|
Nielsen OH, Steenholdt C, Juhl CB, Rogler G. Efficacy and safety of methotrexate in the management of inflammatory bowel disease: A systematic review and meta-analysis of randomized, controlled trials. EClinicalMedicine 2020; 20:100271. [PMID: 32300735 PMCID: PMC7152823 DOI: 10.1016/j.eclinm.2020.100271] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 01/16/2020] [Accepted: 01/16/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The therapeutic role of methotrexate (MTX) for management of inflammatory bowel disease (IBD) remains unclear. METHODS We systematically reviewed randomized, controlled trials (RCTs) of MTX for induction and maintenance of remission in IBD until January 2020 in accordance with PROSPERO protocol (#CRD42018115047). Relative risk (RR) of maintenance of remission, induction of remission, endoscopic disease activity, and adverse events were combined in a meta-analysis. FINDINGS MTX monotherapy was not superior to placebo for induction of clinical remission in Crohn's disease (CD). However, MTX was superior to placebo in maintaining clinical remission of CD. Concomitant therapy with MTX and the TNF inhibitor infliximab (IFX) was not superior to IFX monotherapy in CD. In ulcerative colitis (UC), MTX monotherapy was not superior to placebo neither for induction of clinical remission, nor for maintenance of clinical remission. MTX did not result in superior endoscopic outcomes during induction or maintenance therapy compared with placebo. Regarding adverse events (AEs), our meta-analysis on CD studies showed a significantly higher risk of AEs when comparing MTX versus placebo in studies investigating induction of remission, but not in maintenance of remission. In UC, no such differences in AEs between MTX or placebo were observed. INTERPRETATION Current data support the efficacy of parenteral MTX monotherapy for maintenance of clinical remission in CD. MTX is not confirmed to be effective for treatment of UC or for induction of remission in CD. No evidence supports concomitant MTX to improve efficacy of IFX (no other biologics investigated).
Collapse
Affiliation(s)
- Ole Haagen Nielsen
- Department of Gastroenterology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
- Corresponding author at: Department of Gastroenterology D112, Herlev Hospital, University of Copenhagen, Borgmester Ib Juuls Vej 1, Herlev DK-2730, Denmark.
| | - Casper Steenholdt
- Department of Gastroenterology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Carsten Bogh Juhl
- Research Unit for Musculoskeletal Function and Physiotherapy, University of Southern Denmark, Odense, Denmark
- Department of Physiotherapy and Occupational Therapy, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Gerhard Rogler
- Department of Gastroenterology and Hepatology, University Hospital of Zürich, Zürich, Switzerland
| |
Collapse
|
42
|
Pirani V, Pelliccioni P, De Turris S, Rosati A, Franceschi A, Pasanisi P, Gesuita R, Nicolai M, Mariotti C. Intraocular Inflammation Control and Changes in Retinal and Choroidal Architecture in Refractory Non-Infectious Uveitis Patients after Adalimumab Therapy. J Clin Med 2020; 9:E510. [PMID: 32069898 PMCID: PMC7074084 DOI: 10.3390/jcm9020510] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 02/09/2020] [Accepted: 02/11/2020] [Indexed: 12/11/2022] Open
Abstract
Background: Non-infectious uveitis represents a leading cause of visual impairment, and inflammation control represents a major priority in tackling visual acuity loss due to complications such as macular edema; different immunomodulatory drugs are currently being used, including anti-TNF-alpha Adalimumab. Methods: This was a monocentric observational study of 18 eyes of 18 patients with non-infectious uveitis treated with Adalimumab. The primary endpoint was the control of ocular inflammation. The secondary endpoints included the study of macular and choroidal thickness and architecture, visual acuity, changes in other treatments, and adverse effects. Results: Ocular inflammation was controlled at 12 months for 83.3% of patients. Central macular thickness improved from a median of 229.75 µm at baseline to 213 µm at 12 months, while choroidal thickness decreased by 11.54% at the end of the follow-up. A reduction of vasculitis on fluorescein angiography and of hyperreflective spots on optical coherence tomography was noted. Visual acuity also improved from 0.51 (logMAR) before treatment to 0.24 at more than 12 months (p = 0.01). A total of 11.1% of patients experienced side effects. Conclusion: Our study confirms the efficacy of adalimumab for the control of ocular inflammation, visual acuity preservation, and for corticosteroid sparing.
Collapse
Affiliation(s)
- Vittorio Pirani
- Eye Clinic, Polytechnic University of Marche, via Conca 61, 60126 Ancona, Italy; (V.P.); (S.D.T.); (A.R.); (A.F.); (P.P.); (M.N.); (C.M.)
| | - Paolo Pelliccioni
- Eye Clinic, Polytechnic University of Marche, via Conca 61, 60126 Ancona, Italy; (V.P.); (S.D.T.); (A.R.); (A.F.); (P.P.); (M.N.); (C.M.)
| | - Serena De Turris
- Eye Clinic, Polytechnic University of Marche, via Conca 61, 60126 Ancona, Italy; (V.P.); (S.D.T.); (A.R.); (A.F.); (P.P.); (M.N.); (C.M.)
| | - Alessandro Rosati
- Eye Clinic, Polytechnic University of Marche, via Conca 61, 60126 Ancona, Italy; (V.P.); (S.D.T.); (A.R.); (A.F.); (P.P.); (M.N.); (C.M.)
| | - Alessandro Franceschi
- Eye Clinic, Polytechnic University of Marche, via Conca 61, 60126 Ancona, Italy; (V.P.); (S.D.T.); (A.R.); (A.F.); (P.P.); (M.N.); (C.M.)
| | - Pierangelo Pasanisi
- Eye Clinic, Polytechnic University of Marche, via Conca 61, 60126 Ancona, Italy; (V.P.); (S.D.T.); (A.R.); (A.F.); (P.P.); (M.N.); (C.M.)
| | - Rosaria Gesuita
- Centre of Epidemiology and Biostatistics, Polytechnic University of Marche, via Conca 61, 60126 Ancona, Italy;
| | - Michele Nicolai
- Eye Clinic, Polytechnic University of Marche, via Conca 61, 60126 Ancona, Italy; (V.P.); (S.D.T.); (A.R.); (A.F.); (P.P.); (M.N.); (C.M.)
| | - Cesare Mariotti
- Eye Clinic, Polytechnic University of Marche, via Conca 61, 60126 Ancona, Italy; (V.P.); (S.D.T.); (A.R.); (A.F.); (P.P.); (M.N.); (C.M.)
| |
Collapse
|
43
|
Thomas PWA, Chin PKL, Barclay ML. A nationwide survey on therapeutic drug monitoring of anti-tumour necrosis factor agents for inflammatory bowel disease. Intern Med J 2020; 51:341-347. [PMID: 32043746 DOI: 10.1111/imj.14778] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 01/20/2020] [Accepted: 01/28/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Routine therapeutic drug monitoring (TDM) during treatment with anti-tumour necrosis factor (anti-TNF) agents in inflammatory bowel disease may increase treatment efficacy and cost-effectiveness, and reduce the risk of loss of response. AIMS To assess the current use of anti-TNF agent TDM, including trough concentration and anti-drug antibodies, among gastroenterology practitioners in New Zealand. METHODS A web-based survey was delivered to gastroenterologists and advanced trainees in New Zealand, identified by the New Zealand Society of Gastroenterology. RESULTS The response rate was 36% (48/134). Adalimumab was the most common initial anti-TNF agent used (78%, infliximab 22%). Ninety-three percent of those who completed the survey used TDM, mainly in cases of non-response or loss or response. Most respondents (93% and 83% for adalimumab and infliximab, respectively) measured trough concentrations within 24 h prior to the next administration. In patients in clinical remission but with endoscopic inflammation on anti-TNF agents, 72% would measure drug concentrations. In the presence of anti-drug antibodies, 45% would add an immunomodulator in patients with active disease and 47% would add an immunomodulator in patients in remission. With low trough concentrations, 77% would make no changes if the patient was in remission, and 75% would increase the dose in case of active disease. CONCLUSION TDM was routinely used among inflammatory bowel disease gastroenterology clinicians who responded to this survey. However, interpretation of results and decision-making is variable, suggesting more guidance is required.
Collapse
Affiliation(s)
| | - Paul K L Chin
- Department of Clinical Pharmacology, Christchurch Hospital, Christchurch, New Zealand
| | - Murray L Barclay
- Department of Clinical Pharmacology, Christchurch Hospital, Christchurch, New Zealand.,Department of Gastroenterology, Christchurch Hospital, Christchurch, New Zealand
| |
Collapse
|
44
|
Gil-candel M, Gascón-cánovas JJ, Urbieta-sanz E, Rentero-redondo L, Onteniente-candela M, Iniesta-navalón C. Comparison of drug survival between infliximab and adalimumab in inflammatory bowel disease. Int J Clin Pharm 2020; 42:500-7. [DOI: 10.1007/s11096-020-00978-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 01/22/2020] [Indexed: 12/16/2022]
|
45
|
Ding X, Zhu R, Wu J, Xue L, Gu M, Miao L. Early Adalimumab and Anti-Adalimumab Antibody Levels for Prediction of Primary Nonresponse in Ankylosing Spondylitis Patients. Clin Transl Sci 2020; 13:547-554. [PMID: 31961477 PMCID: PMC7214645 DOI: 10.1111/cts.12738] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 11/02/2019] [Indexed: 12/11/2022] Open
Abstract
This study aimed at exploring the concentration‐effect relationship of adalimumab and early adalimumab and anti‐adalimumab antibody (AAA) levels in predicting primary nonresponse in a real‐world pilot cohort of patients with ankylosing spondylitis. Thirty‐one patients were included. The Ankylosing Spondylitis Disease Activity Score improved with increasing adalimumab trough level at week 12 and reached a major improvement with levels between 8 and 12 μg/mL. Moreover, weeks 4 and 2 adalimumab levels below 4.28 and 3.37 μg/mL were predictive of primary nonresponse (area under the curve (AUC) = 0.89, 0.88; P = 0.0003, P = 0.034, respectively). Week 4 AAA signal‐to‐noise levels were significantly higher among primary nonresponders, and the cutoff for primary nonresponse prediction was above 5.31 (AUC = 0.81; P = 0.004). Adalimumab trough levels in a range of 8–12 μg/mL are optimum to reach major improvement, and lower adalimumab with higher AAA levels at the early stage (week 4) predict primary nonresponse by supporting proactive monitoring to optimize adalimumab therapy.
Collapse
Affiliation(s)
- Xiaoliang Ding
- Department of Clinical Pharmacology, the First Affiliated Hospital of Soochow University, Suzhou, China.,Institute for Interdisciplinary Drug Research and Translational Sciences, College of Pharmaceutical Sciences, Soochow University, Suzhou, China
| | - Ruifang Zhu
- Department of Clinical Pharmacology, the First Affiliated Hospital of Soochow University, Suzhou, China.,Institute for Interdisciplinary Drug Research and Translational Sciences, College of Pharmaceutical Sciences, Soochow University, Suzhou, China
| | - Jian Wu
- Department of Rheumatology, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Ling Xue
- Department of Clinical Pharmacology, the First Affiliated Hospital of Soochow University, Suzhou, China.,Institute for Interdisciplinary Drug Research and Translational Sciences, College of Pharmaceutical Sciences, Soochow University, Suzhou, China
| | - Meihua Gu
- Department of Rheumatology, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Liyan Miao
- Department of Clinical Pharmacology, the First Affiliated Hospital of Soochow University, Suzhou, China.,Institute for Interdisciplinary Drug Research and Translational Sciences, College of Pharmaceutical Sciences, Soochow University, Suzhou, China
| |
Collapse
|
46
|
Hirai F, Takeda T, Takada Y, Kishi M, Beppu T, Takatsu N, Miyaoka M, Hisabe T, Yao K, Ueki T. Efficacy of enteral nutrition in patients with Crohn's disease on maintenance anti-TNF-alpha antibody therapy: a meta-analysis. J Gastroenterol 2020; 55:133-141. [PMID: 31641874 PMCID: PMC6981109 DOI: 10.1007/s00535-019-01634-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 09/28/2019] [Indexed: 02/04/2023]
Abstract
Enteral nutrition (EN) is effective in Crohn's disease (CD) patients and has been shown to have an inhibitory effect on loss of response to anti-tumor necrosis factor (TNF)-alpha antibody therapy; however, the current level of evidence is not sufficient. The objective of this meta-analysis was to determine whether EN in combination anti-TNF-alpha antibody therapy is useful in maintaining remission. PubMed was used to identify all relevant studies. A total of nine articles were identified including one randomized control trial, two prospective cohort studies, and six retrospective cohort studies. We performed a meta-analysis on all these articles to assess the remission maintenance effect of EN (n = 857). The remission or response maintenance effect in the EN group was 203/288 (70.5%), which was higher than 306/569 (53.8%) in the non-EN group. The odds ratio for long-term remission or response using fixed effects model and random effects model were 2.23 (95% CI 1.60-3.10) and 2.19 (95% CI 1.49-3.22), respectively. The usefulness of EN was unclear in two prospective studies that were conducted immediately after remission induction with anti-TNF-alpha antibody therapy was detected. Differences in the definition of relapse and the observation period among articles were considered to be limitations. This analysis suggests that EN is effective for maintaining remission in patients already in remission or response as a result of anti-TNF-alpha antibody maintenance therapy.
Collapse
Affiliation(s)
- Fumihito Hirai
- Inflammatory Bowel Disease Center, Fukuoka University Chikushi Hospital, Chikushino, Fukuoka Japan ,Department of Gastroenterology, Fukuoka University Faculty of Medicine, 7-45-1, Nanakuma, Jonan-ku, Fukuoka, 814-0180 Japan
| | - Teruyuki Takeda
- Inflammatory Bowel Disease Center, Fukuoka University Chikushi Hospital, Chikushino, Fukuoka Japan ,Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Fukuoka Japan
| | - Yasumichi Takada
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Fukuoka Japan
| | - Masahiro Kishi
- Inflammatory Bowel Disease Center, Fukuoka University Chikushi Hospital, Chikushino, Fukuoka Japan ,Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Fukuoka Japan
| | - Tsuyoshi Beppu
- Inflammatory Bowel Disease Center, Fukuoka University Chikushi Hospital, Chikushino, Fukuoka Japan ,Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Fukuoka Japan
| | - Noritaka Takatsu
- Inflammatory Bowel Disease Center, Fukuoka University Chikushi Hospital, Chikushino, Fukuoka Japan
| | - Masaki Miyaoka
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Fukuoka Japan
| | - Takashi Hisabe
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Fukuoka Japan
| | - Kenshi Yao
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Fukuoka Japan
| | - Tosiharu Ueki
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Fukuoka Japan
| |
Collapse
|
47
|
|
48
|
Affiliation(s)
- Maria T Abreu
- Division of Gastroenterology, Crohn's and Colitis Center, University of Miami Miller School of Medicine, 1011 NW 15th Street, Gautier, Suite 510 (D-149), Miami, FL, 33136, USA.
| |
Collapse
|
49
|
|
50
|
Khoury T, Ilan Y. Introducing Patterns of Variability for Overcoming Compensatory Adaptation of the Immune System to Immunomodulatory Agents: A Novel Method for Improving Clinical Response to Anti-TNF Therapies. Front Immunol 2019; 10:2726. [PMID: 31824506 PMCID: PMC6879658 DOI: 10.3389/fimmu.2019.02726] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 11/06/2019] [Indexed: 12/18/2022] Open
Abstract
Primary lack of response and secondary loss of response (LOR) are major obstacles to the use of anti–tumor necrosis factor (TNF)-based therapies in patients with rheumatoid arthritis or inflammatory bowel disease. Here, we review the mechanisms and methods for predicting LOR and the currently used methods for overcoming the ineffectiveness of anti-TNFs. The complex functions of TNF and anti-TNF antibodies, which can promote both pro- or anti-inflammatory actions, and the factors that affect the induction of immune tolerance to their effects are presented. The lack of rules and the continuous dynamics of the immune processes partly underlie the unpredictability of the response to anti-TNFs. Variability is inherent to biological systems, including immune processes, and intra/inter-patient variability has been described in the response to drugs. This variability is viewed as a compensatory adaptation mechanism of the immune system in response to drugs and may contribute to treatment LOR. Dose reductions and drug holidays have been tested in patients treated with anti-TNFs. Regular dose-based regimens may be incompatible with physiological variability, further contributing to treatment inefficacy. We present the concept of overcoming immune system adaptation to anti-TNFs by introducing patient-tailored patterns of variability to treatment regimens.
Collapse
Affiliation(s)
- Tawfik Khoury
- Department of Gastroenterology, Galilee Medical Center, Nahariya, Israel.,Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Yaron Ilan
- Department of Medicine, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| |
Collapse
|