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Pinto FPJ, Dutra RDM, Almeida LC, Craveiro MMS, Baima JP, Saad-Hossne R, Sassaki LY. Vedolizumab Safety During Pregnancy and Lactation in a Patient with Ulcerative Colitis: A Case Report. Clin Exp Gastroenterol 2024; 17:165-171. [PMID: 38799766 PMCID: PMC11122291 DOI: 10.2147/ceg.s457256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 05/07/2024] [Indexed: 05/29/2024] Open
Abstract
Background Inflammatory bowel disease (IBD) affects young adults of reproductive age, and questions related to pregnancy and breastfeeding are common in clinical practice. Most medications used to treat IBD are considered safe during pregnancy, except methotrexate and small molecules such as tofacitinib. Despite few studies regarding vedolizumab (VDZ) safety, it appears to be safe during pregnancy. Therefore, this study aimed to report the management of ulcerative colitis in pregnant patient refractory to anti-tumor necrosis factor (TNF) agents using VDZ. Case Report A female, 38 years old, with ulcerative colitis was refractory to conventional treatment with mesalazine, sulfasalazine, and azathioprine. She was hospitalized at six weeks of gestation with severe acute colitis requiring the use of infliximab (IFX) to induce remission. She had a spontaneous abortion at nine weeks of gestation after the second dose of IFX. Since there was no endoscopic improvement after six months of IFX treatment, VDZ treatment was initiated. During the VDZ infusion period, the patient discovered that she was pregnant with twins, leading to the discussion of the risks and benefits of continuing the VDZ. The patient presented with disease clinical remission with the use of VDZ, and the babies were born at 34 weeks of gestation without complications. Breastfeeding was also performed without complications. Conclusion Continued VDZ medication is safe during pregnancy and breastfeeding, with adverse events similar to anti-TNF therapy.
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Affiliation(s)
| | - Renata de Medeiros Dutra
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu, São Paulo State, Brazil
| | - Livia Cafundo Almeida
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu, São Paulo State, Brazil
| | | | - Julio Pinheiro Baima
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu, São Paulo State, Brazil
| | - Rogerio Saad-Hossne
- Department of Surgery, São Paulo State University (Unesp), Medical School, Botucatu, São Paulo State, Brazil
| | - Ligia Yukie Sassaki
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu, São Paulo State, Brazil
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Mocci G, Tursi A, Onidi FM, Usai-Satta P, Pes GM, Dore MP. Ustekinumab in the Treatment of Inflammatory Bowel Diseases: Evolving Paradigms. J Clin Med 2024; 13:1519. [PMID: 38592377 PMCID: PMC10933994 DOI: 10.3390/jcm13051519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 03/04/2024] [Accepted: 03/05/2024] [Indexed: 04/10/2024] Open
Abstract
Inflammatory bowel diseases, comprising Crohn's disease (CD) and ulcerative colitis (UC), are chronic, relapsing, and remitting immune-mediated inflammatory diseases affecting the gastrointestinal tract. Ustekinumab (UST) is a monoclonal antibody that blocks the p40 subunit of the anti-interleukin (IL) 12/23. Pivotal trials (CERTIFI and UNITI-IM for CD, UNIFI for UC) established the efficacy of UST for the induction and maintenance of remission in both CD and UC, with the most favorable results in naïve patients to biologics. In recent years, a wealth of 'real-world' data has emerged supporting positive clinical, endoscopic, and histological outcomes in patients treated with UST, as well as reassuring safety data. More recently, the results of the first head-to-head trials of UST and tumor necrosis factor (TNF) antagonists were reported. Moreover, a number of studies exploring the role of UST in specific clinical settings, such as perianal CD, postoperative complications and recurrence, extraintestinal manifestations, chronic antibiotic-refractory pouchitis, and pregnancy, were reported. This review explores the results reported to date on UST, including those from pivotal trials, real-world data, and emerging studies regarding therapeutic drug monitoring and immunogenicity. The safety profile of UST was also reviewed.
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Affiliation(s)
- Giammarco Mocci
- Division of Gastroenterology, “Brotzu” Hospital, 09124 Cagliari, Italy; (G.M.); (F.M.O.); (P.U.-S.)
| | - Antonio Tursi
- Territorial Gastroenterology Service, ASL BAT, 76123 Andria, Italy;
- Department of Medical and Surgical Sciences, School of Medicine, Catholic University, 00168 Rome, Italy
| | - Francesca Maria Onidi
- Division of Gastroenterology, “Brotzu” Hospital, 09124 Cagliari, Italy; (G.M.); (F.M.O.); (P.U.-S.)
| | - Paolo Usai-Satta
- Division of Gastroenterology, “Brotzu” Hospital, 09124 Cagliari, Italy; (G.M.); (F.M.O.); (P.U.-S.)
| | - Giovanni Mario Pes
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy;
| | - Maria Pina Dore
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy;
- Baylor College of Medicine, One Baylor Plaza Blvd., Houston, TX 77030, USA
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3
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Pugliese D, Privitera G, Gisbert JP, Chaparro M. New drugs for the treatment of IBD during conception, pregnancy, and lactation. Dig Liver Dis 2024; 56:235-241. [PMID: 37718225 DOI: 10.1016/j.dld.2023.08.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 08/11/2023] [Accepted: 08/21/2023] [Indexed: 09/19/2023]
Abstract
The management of inflammatory bowel disease requires continuous medical therapy to achieve and maintain disease control. Thus, women can be exposed to different drugs during conception, pregnancy, and lactation with potentially harmful effects on the mother, foetus, or nursing infant. Conventional drugs and anti-tumour necrosis factor (TNF)-α are considered safe and can be maintained throughout all these phases. Emergent, although limited, data support safety of vedolizumab and ustekinumab, with pregnancy, as well as maternal and neonatal outcomes comparable to women unexposed or treated with anti TNF-α drugs. Placental pharmacokinetics differ between these two biologics, with an inverse infant-to-maternal ratio for vedolizumab, whereas ustekinumab shows a similar profile to anti TNF-α drugs. The clearance of vedolizumab in exposed offspring seems to be faster than anti TNF-α, estimated around 15 and 19 weeks of age, respectively. Currently, the decision to interrupt or maintain these treatments is up to physicians' judgement on a case-by-case basis. In animal studies, Janus kinase (JAK) inhibitors and ozanimod have shown embryotoxicity and teratogenicity. Moreover, tofacitinib and filgotinib seemingly affect female fertility. This review summarizes all existing data on the effects of administration of non-anti-TNF-α biologic agents and small molecules, during conception, pregnancy, and lactation.
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Affiliation(s)
- Daniela Pugliese
- Dipartimento di Scienze Mediche e Chirurgiche, CEMAD - IBD UNIT, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Giuseppe Privitera
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy
| | - Javier P Gisbert
- Department of Gastroenterology, Inflammatory Bowel Disease Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Diego de León, 62, Madrid 28006, Spain
| | - María Chaparro
- Department of Gastroenterology, Inflammatory Bowel Disease Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Diego de León, 62, Madrid 28006, Spain.
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4
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Julsgaard M, Wieringa JW, Baunwall SMD, Bibby BM, Driessen GJA, Kievit L, Brodersen JB, Poulsen A, Kjeldsen J, Hansen MM, Tang HQ, Balmer CL, Glerup H, Seidelin JB, Haderslev KV, Svenningsen L, Wildt S, Juel MA, Neumann A, Fuglsang J, Jess T, Haase AM, Hvas CL, Kelsen J, Janneke van der Woude C. Infant Ustekinumab Clearance, Risk of Infection, and Development After Exposure During Pregnancy. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00083-1. [PMID: 38278191 DOI: 10.1016/j.cgh.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND Evidence on ustekinumab safety in pregnancy is gradually expanding, but its clearance in the postnatal period is unknown. The aim of this study was to investigate ustekinumab concentrations in umbilical cord blood and rates of clearance after birth, as well as how these correlate with maternal drug concentrations, risk of infection, and developmental milestones during the first year of life. METHODS Pregnant women with inflammatory bowel disease were prospectively recruited from 19 hospitals in Denmark and the Netherlands between 2018 and 2022. Infant infections leading to hospitalization/antibiotics and developmental milestones were assessed. Serum ustekinumab concentrations were measured at delivery and specific time points. Nonlinear regression analysis was applied to estimate clearance. RESULTS In 78 live-born infants from 76 pregnancies, we observed a low risk of adverse pregnancy outcomes and normal developmental milestones. At birth, the median infant-mother ustekinumab ratio was 2.18 (95% confidence interval, 1.69-2.81). Mean time to infant clearance was 6.7 months (95% confidence interval, 6.1-7.3 months). One in 4 infants at 6 months had an extremely low median concentration of 0.015 μg/mL (range 0.005-0.12 μg/mL). No variation in median ustekinumab concentration was noted between infants with (2.8 [range 0.4-6.9] μg/mL) and without (3.1 [range 0.7-11.0] μg/mL) infections during the first year of life (P = .41). CONCLUSIONS No adverse signals after intrauterine exposure to ustekinumab were observed with respect to pregnancy outcome, infections, or developmental milestones during the first year of life. Infant ustekinumab concentration was not associated with risk of infections. With the ustekinumab clearance profile, live attenuated vaccination from 6 months of age seems of low risk.
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Affiliation(s)
- Mette Julsgaard
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark; Center for Molecular Prediction of Inflammatory Bowel Disease, Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark.
| | - Jantien W Wieringa
- Department of Pediatrics, Haaglanden Medical Center, The Hague, the Netherlands; Division of Paediatric Infectious Diseases and Immunology, Department of Pediatrics, Sophia Children's Hospital, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Simon M D Baunwall
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Bo M Bibby
- Department of Biostatistics, University of Aarhus, Aarhus, Denmark
| | - Gertjan J A Driessen
- Department of Pediatrics, MosaKids Children's Hospital, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Linda Kievit
- Department of Medicine, Gjødstrup Hospital, Gjødstrup, Denmark
| | - Jacob B Brodersen
- Department of Gastroenterology, Esbjerg Hospital, University Hospital of Southern Denmark, Esbjerg, Denmark; Department of Regional Health Science, University of Southern Denmark, Esbjerg, Denmark
| | - Anja Poulsen
- Digestive Disease Center, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Jens Kjeldsen
- Department of Medical Gastrointestinal Diseases, Odense University Hospital, Odense, Denmark
| | - Mette M Hansen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Hai Q Tang
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Denmark
| | - Christina L Balmer
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Henning Glerup
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Jakob B Seidelin
- Department of Gastroenterology and Hepatology, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - Kent V Haderslev
- Department of Gastroenterology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Lise Svenningsen
- Department of Internal Medicine, Horsens Regional Hospital, Horsens, Denmark
| | - Signe Wildt
- Unit of Medical and Surgical Gastroenterology, Hvidovre University Hospital, Hvidovre, Denmark
| | - Mie A Juel
- Department of Gastroenterology, Esbjerg Hospital, University Hospital of Southern Denmark, Esbjerg, Denmark; Department of Internal Medicine, Vejle Hospital, Vejle, Denmark
| | - Anders Neumann
- Department of Internal Medicine, Viborg Regional Hospital, Viborg, Denmark
| | - Jens Fuglsang
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Denmark
| | - Tine Jess
- Center for Molecular Prediction of Inflammatory Bowel Disease, Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark; Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Anne-Mette Haase
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Christian L Hvas
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark; Institute of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
| | - Jens Kelsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark; Institute of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
| | - C Janneke van der Woude
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Meyer A, Miranda S, Drouin J, Weill A, Carbonnel F, Dray-Spira R. Safety of Vedolizumab and Ustekinumab Compared With Anti-TNF in Pregnant Women With Inflammatory Bowel Disease. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00010-7. [PMID: 38199301 DOI: 10.1016/j.cgh.2023.12.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 12/20/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND & AIMS Limited data are available on the consequences of prenatal exposure to vedolizumab and ustekinumab. We aimed to compare the safety of vedolizumab and ustekinumab with that of anti-tumor necrosis factor (TNF) in pregnant women with inflammatory bowel diseases (IBD). METHODS Using nationwide, comprehensive data of the EPI-MERES registry, we identified pregnancies in women with IBD in France, exposed to anti-TNF, vedolizumab, and ustekinumab between 2014 and 2021. We compared pregnancy outcomes and complications in the offspring according to treatment exposure during pregnancy. We applied a propensity score matching for maternal, IBD, and pregnancy characteristics. RESULTS Three hundred ninety-eight pregnancies exposed to vedolizumab were compared with 1592 pregnancies exposed to anti-TNF; 464 pregnancies exposed to ustekinumab were compared with 1856 pregnancies exposed to anti-TNF. Overall, compared with anti-TNF, neither vedolizumab nor ustekinumab was associated with increased risks of abortion, caesarean section, stillbirth, preterm birth, serious infections, malignancies, or congenital abnormality in children. Women exposed to ustekinumab had an increased risk of small for gestational age births. CONCLUSIONS Overall, the safety of vedolizumab and ustekinumab compared with anti-TNF use during pregnancy is reassuring. Further studies are needed to confirm these findings.
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Affiliation(s)
- Antoine Meyer
- EPI-PHARE, Épidémiologie des produits de santé, Saint-Denis, France; Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre & Université Paris-Saclay, Le Kremlin Bicêtre, France.
| | - Sara Miranda
- EPI-PHARE, Épidémiologie des produits de santé, Saint-Denis, France
| | - Jérôme Drouin
- EPI-PHARE, Épidémiologie des produits de santé, Saint-Denis, France
| | - Alain Weill
- EPI-PHARE, Épidémiologie des produits de santé, Saint-Denis, France
| | - Franck Carbonnel
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre & Université Paris-Saclay, Le Kremlin Bicêtre, France
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Wang Y, Smolinski NE, Thai TN, Sarayani A, Ewig C, Rasmussen SA, Winterstein AG. Common teratogenic medication exposures-a population-based study of pregnancies in the United States. Am J Obstet Gynecol MFM 2024; 6:101245. [PMID: 38061552 DOI: 10.1016/j.ajogmf.2023.101245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/21/2023] [Accepted: 11/27/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND Risk mitigation for most teratogenic medications relies on risk communication via drug label, and prenatal exposures remain common. Information on the types of and risk factors for prenatal exposures to medications with teratogenic risk can guide strategies to reduce exposure. OBJECTIVE This study aimed to identify medications with known or potential teratogenic risk commonly used during pregnancy among privately insured persons. STUDY DESIGN We used the Merative™ MarketScan® Commercial Database to identify pregnancies with live or nonlive (ectopic pregnancies, spontaneous and elective abortions, stillbirths) outcomes among persons aged 12 to 55 years from 2011 to 2018. Start/end dates of medication exposure and pregnancy outcomes were identified via an adapted algorithm based on validation studies. We required continuous health plan enrollment from 90 days before conception until 30 days after the pregnancy end date. Medications with known or potential teratogenic risk were selected from TERIS (Teratogen Information System) and drug monographs based on the level of risk and quality of evidence (138 with known and 60 with potential risk). We defined prenatal exposure on the basis of ≥1 outpatient pharmacy claim or medical encounter for medication administration during target pregnancy periods considering medication risk profiles (eg, risk only in the first trimester or at a certain dose threshold). Sex hormones and hormone analogs, and abortion and postpartum/abortion hemorrhage treatments were not considered as teratogenic medications because of challenges in separating pregnancy-related indications, nor were opioids (because of complex risk-benefit considerations) or antiobesity medications if their only teratogenic mechanism was weight loss. RESULTS Among all pregnancies, the 10 medications with known teratogenic risk and the highest prenatal exposures were sulfamethoxazole/trimethoprim (1988 per 100,000 pregnancy-years), high-dose fluconazole (1248), topiramate (351), lisinopril (144), warfarin (57), losartan (56), carbamazepine (50), valproate (49), vedolizumab (28 since 2015), and valsartan (25). Prevalence of exposure to sulfamethoxazole/trimethoprim decreased from 2346 to 1453 per 100,000 pregnancy-years from 2011 to 2018, but prevalence of exposure to vedolizumab increased 6-fold since its approval in 2015. Prenatal exposures in the first trimester were higher among nonlive pregnancies than among live-birth pregnancies, with the largest difference observed for warfarin (nonlive 370 vs live birth 78), followed by valproate (258 vs 86) and topiramate (1728 vs 674). Prenatal exposures to medications with potential teratogenic risk were most prevalent for low-dose fluconazole (6495), metoprolol (1325), and atenolol (448). The largest first-trimester exposure differences between nonlive and live-birth pregnancies were observed for lithium (242 vs 89), gabapentin (1639 vs 653), and duloxetine (1914 vs 860). Steady increases in hydralazine and gabapentin exposures were observed during the study years, whereas atenolol exposure decreased (561 to 280). CONCLUSION Several medications with teratogenic risk for which there are potentially safer alternatives continue to be used during pregnancy. The fluctuating rates of prenatal exposure observed for select teratogenic medications suggest that regular reevaluation of risk mitigation strategies is needed. Future research focusing on understanding the clinical context of medication use is necessary to develop effective strategies for reducing exposures to medications with teratogenic risk during pregnancy.
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Affiliation(s)
- Yanning Wang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL (Ms Wang and Drs Smolinski, Thai, Sarayani, Ewig, and Winterstein); Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL (Ms Wang)
| | - Nicole E Smolinski
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL (Ms Wang and Drs Smolinski, Thai, Sarayani, Ewig, and Winterstein)
| | - Thuy Nhu Thai
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL (Ms Wang and Drs Smolinski, Thai, Sarayani, Ewig, and Winterstein); Faculty of Pharmacy, Ho Chi Minh City University of Technology, Ho Chi Minh City, Vietnam (Dr Thai)
| | - Amir Sarayani
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL (Ms Wang and Drs Smolinski, Thai, Sarayani, Ewig, and Winterstein)
| | - Celeste Ewig
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL (Ms Wang and Drs Smolinski, Thai, Sarayani, Ewig, and Winterstein)
| | - Sonja A Rasmussen
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (Dr Rasmussen)
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL (Ms Wang and Drs Smolinski, Thai, Sarayani, Ewig, and Winterstein); Department of Epidemiology, College of Medicine and College of Public Health and Health Professions, University of Florida, Gainesville, FL (Dr Winterstein); Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, FL (Dr Winterstein).
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Caballero-Mateos AM, Quesada-Caballero M, Cañadas-De la Fuente GA, Caballero-Vázquez A, Contreras-Chova F. IBD and Motherhood: A Journey through Conception, Pregnancy and Beyond. J Clin Med 2023; 12:6192. [PMID: 37834837 PMCID: PMC10573266 DOI: 10.3390/jcm12196192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 09/14/2023] [Accepted: 09/19/2023] [Indexed: 10/15/2023] Open
Abstract
Inflammatory Bowel Disease (IBD) presents distinct challenges during pregnancy due to its influence on maternal health and pregnancy outcomes. This literature review aims to dissect the existing scientific evidence on pregnancy in women with IBD and provide evidence-based recommendations for clinical management. A comprehensive search was conducted across scientific databases, selecting clinical studies, systematic reviews, and other pertinent resources. Numerous studies have underscored an increased risk of complications during pregnancy for women with IBD, including preterm birth, low birth weight, neonates small for gestational age, and congenital malformations. Nevertheless, it's evident that proactive disease management before and throughout pregnancy can mitigate these risks. Continuation of IBD treatment during pregnancy and breastfeeding is deemed safe with agents like thiopurines, anti-TNF, vedolizumab, or ustekinumab. However, there's a call for caution when combining treatments due to the heightened risk of severe infections in the first year of life. For small molecules, their use is advised against in both scenarios. Effective disease management, minimizing disease activity, and interdisciplinary care are pivotal in attending to women with IBD. The emphasis is placed on the continual assessment of maternal and infant outcomes and an expressed need for further research to enhance the understanding of the ties between IBD and adverse pregnancy outcomes.
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8
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Honap S, Netter P, Danese S, Peyrin-Biroulet L. An update on the safety of long-term vedolizumab use in inflammatory bowel disease. Expert Opin Drug Saf 2023; 22:767-776. [PMID: 37610086 DOI: 10.1080/14740338.2023.2247976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/10/2023] [Indexed: 08/24/2023]
Abstract
INTRODUCTION Vedolizumab (Entyvio) is a humanized monoclonal antibody that disrupts the interaction between α4β7 integrin on circulating T-lymphocytes and MAdCAM-1 on the vascular endothelium to prevent their egress to sites of gut inflammation. It has proven therapeutic efficacy for the treatment of moderate-to-severe Crohn's disease, ulcerative colitis, and pouchitis. AREAS COVERED This narrative review assesses the safety profile of vedolizumab from the registration trial programs, open-label extension studies, observational real-world data, and pooled safety analyses. This includes an evaluation of the long-term overall safety in special populations typically underrepresented in clinical trials. EXPERT OPINION Vedolizumab is an effective therapy for inflammatory bowel disease with a well-established safety profile. No unexpected long-term safety signals have been identified. Safety data in pregnancy, in pediatric and elderly populations, in patients undergoing surgery, and in patients with a prior history of cancer are reassuring. Due to its safety merits, we propose that vedolizumab is an excellent candidate for advanced combination treatment with an anti-cytokine approach using another biologic or novel small molecule inhibitor. This is important in patients with medically refractory IBD, in patients at high risk of developing disease-related complications, or in patients with concomitant uncontrolled immune-mediated inflammatory diseases.
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Affiliation(s)
- Sailish Honap
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust, London, UK
- School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Patrick Netter
- Ingénierie Moléculaire et Ingénierie Articulaire (IMoPA), UMR-7365 CNRS, Faculté de Médecine, University of Lorraine and University Hospital of Nancy, Nancy, France
| | - Silvio Danese
- Department of Gastroenterology and Endoscopy, IRCCS San Raffaele Hospital and Vita-Salute San Raffaele University, Milan, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology, Nancy University Hospital, Vandœuvre-lès-Nancy, France
- INFINY Institute, Nancy University Hospital, Vandœuvre-lès-Nancy, France
- Groupe Hospitalier privé Ambroise Paré - Hartmann, Paris IBD center, Neuilly sur Seine, France
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
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9
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Lenti MV, Scribano ML, Biancone L, Ciccocioppo R, Pugliese D, Pastorelli L, Fiorino G, Savarino E, Caprioli FA, Ardizzone S, Fantini MC, Tontini GE, Orlando A, Sampietro GM, Sturniolo GC, Monteleone G, Vecchi M, Kohn A, Daperno M, D’Incà R, Corazza GR, Di Sabatino A. Personalize, participate, predict, and prevent: 4Ps in inflammatory bowel disease. Front Med (Lausanne) 2023; 10:1031998. [PMID: 37113615 PMCID: PMC10126747 DOI: 10.3389/fmed.2023.1031998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 03/14/2023] [Indexed: 04/29/2023] Open
Abstract
Inflammatory bowel disease (IBD), which includes Crohn's disease (CD) and ulcerative colitis (UC), is a complex, immune-mediated, disorder which leads to several gastrointestinal and systemic manifestations determining a poor quality of life, disability, and other negative health outcomes. Our knowledge of this condition has greatly improved over the last few decades, and a comprehensive management should take into account both biological (i.e., disease-related, patient-related) and non-biological (i.e., socioeconomic, cultural, environmental, behavioral) factors which contribute to the disease phenotype. From this point of view, the so called 4P medicine framework, including personalization, prediction, prevention, and participation could be useful for tailoring ad hoc interventions in IBD patients. In this review, we discuss the cutting-edge issues regarding personalization in special settings (i.e., pregnancy, oncology, infectious diseases), patient participation (i.e., how to communicate, disability, tackling stigma and resilience, quality of care), disease prediction (i.e., faecal markers, response to treatments), and prevention (i.e., dysplasia through endoscopy, infections through vaccinations, and post-surgical recurrence). Finally, we provide an outlook discussing the unmet needs for implementing this conceptual framework in clinical practice.
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Affiliation(s)
- Marco Vincenzo Lenti
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
- Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy
| | | | - Livia Biancone
- Unit of Gastroenterology, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Rachele Ciccocioppo
- Gastroenterology Unit, Department of Medicine, A.O.U.I. Policlinico G.B. Rossi and University of Verona, Verona, Italy
| | - Daniela Pugliese
- CEMAD Digestive Disease Center, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Luca Pastorelli
- Liver and Gastroenterology Unit, ASST Santi Paolo e Carlo, Milan, Italy
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Gionata Fiorino
- IBD Unit, Ospedale San Camillo-Forlanini, Rome, Italy
- Department of Gastroenterology, San Raffaele Hospital and Vita-Salute San Raffaele University,, Milan, Italy
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Flavio Andrea Caprioli
- Gastroenterology and Endoscopy Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda, Ospedale Maggiore Policlinico and Università degli Studi di Milano, Milan, Italy
| | - Sandro Ardizzone
- Gastroenterology and Digestive Endoscopy Unit, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Massimo Claudio Fantini
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
- Gastroenterology Unit, Azienda Ospedaliero-Universitaria (AOU) di Cagliari, Cagliari, Italy
| | - Gian Eugenio Tontini
- Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milano, Italy
| | - Ambrogio Orlando
- Inflammatory Bowel Disease Unit, Azienda Ospedaliera Ospedali Riuniti "Villa Sofia-Cervello" Palermo, Palermo, Italy
| | | | - Giacomo Carlo Sturniolo
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Giovanni Monteleone
- Unit of Gastroenterology, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Maurizio Vecchi
- Gastroenterology and Endoscopy Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda, Ospedale Maggiore Policlinico and Università degli Studi di Milano, Milan, Italy
| | - Anna Kohn
- Gastroenterology Operative Unit, Azienda Ospedaliera San Camillo-Forlanini FR, Rome, Italy
| | - Marco Daperno
- Division of Gastroenterology, Ospedale Ordine Mauriziano di Torino, Turin, Italy
| | - Renata D’Incà
- Department of Gastroenterology, San Raffaele Hospital and Vita-Salute San Raffaele University,, Milan, Italy
| | - Gino Roberto Corazza
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
- Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy
| | - Antonio Di Sabatino
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
- Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy
- *Correspondence: Antonio Di Sabatino,
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10
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Mahadevan U, Naureckas S, Tikhonov I, Wang Y, Lin CB, Geldhof A, van der Woude CJ. Pregnancy outcomes following periconceptional or gestational exposure to ustekinumab: Review of cases reported to the manufacturer's global safety database. Aliment Pharmacol Ther 2022; 56:477-490. [PMID: 35560249 DOI: 10.1111/apt.16960] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/17/2022] [Accepted: 04/22/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Ustekinumab, a human immunoglobulin G1 monoclonal antibody that binds to and inhibits interleukin (IL)-12/IL-23, is indicated for multiple immune-mediated diseases. Ustekinumab is actively transported across the placenta and theoretically could impact pregnancy outcomes. Limited data on pregnancy outcomes with ustekinumab exposure are available. AIM To assess pregnancy outcomes in patients exposed to ustekinumab during pregnancy METHODS: Cumulative data on medically confirmed ustekinumab-exposed pregnancies from the manufacturer's Global Safety Database were summarised. Descriptive data for pregnancy outcomes were presented overall and by patient subgroups. RESULTS As of 31 August 2020, 408 medically confirmed, prospective, maternal ustekinumab-exposed pregnancies with reported outcomes were identified. The mean maternal age was 31 years. Of the 420 pregnancy outcomes (including 4 sets of twins),a , b 340 (81%) were live births, 51 (12.1%) spontaneous abortions, 25 (6%) elective/induced abortions, 3 (0.7%) stillbirths and 1 (0.2%) ongoing pregnancy with foetal congenital anomaly (CA). Among 340 live births, 33 (9.7%) were born pre-term. The rate of major CAs was similar by indication (Crohn's disease vs psoriasis), ustekinumab dose (45 mg vs 90 mg) and timing and duration of maternal exposure to ustekinumab. Prospective outcomes of pregnancies with paternal periconceptional ustekinumab exposure (n = 87) included 92% live births (1.2% major CA), 5.7% spontaneous abortions and 2.3% elective/induced abortions. CONCLUSIONS Rates of adverse pregnancy outcomes or CAs with ustekinumab exposure were consistent with rates reported for the US general population and do not suggest a higher risk associated with maternal or paternal exposure to ustekinumab.
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Affiliation(s)
- Uma Mahadevan
- University of California San Francisco, San Francisco, California, USA
| | - Saule Naureckas
- Janssen Research and Development, LLC, Raritan, New Jersey, USA
| | - Ilia Tikhonov
- Janssen Research and Development, LLC, Raritan, New Jersey, USA
| | - Yiting Wang
- Janssen Research and Development, LLC, Spring House, Pennsylvania, USA
| | - Connie B Lin
- Janssen Research and Development, LLC, Horsham, Pennsylvania, USA
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11
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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] [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.
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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
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12
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The impact of gender and sex in psoriasis: What to be aware of when treating women with psoriasis. Int J Womens Dermatol 2022; 8:e010. [PMID: 35619672 PMCID: PMC9112394 DOI: 10.1097/jw9.0000000000000010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 02/02/2022] [Indexed: 12/25/2022] Open
Abstract
Psoriasis is a common chronic inflammatory skin disease with an exceptionally high burden for women.
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13
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Lenti MV, Dolby V, Clark T, Hall V, Tattersall S, Fairhurst F, Kenneth C, Walker R, Kemp K, Borg‐Bartolo S, Limdi JK, Taylor J, Townsend T, Subramanian S, Storey D, Assadsangabi A, Stansfield C, Smith P, Byrne D, De Silvestri A, Selinger C. A propensity score-matched, real-world comparison of ustekinumab vs vedolizumab as a second-line treatment for Crohn's disease. The Cross Pennine study II. Aliment Pharmacol Ther 2022; 55:856-866. [PMID: 34935160 PMCID: PMC9305775 DOI: 10.1111/apt.16742] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/06/2021] [Accepted: 12/09/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND The optimal choice of biological agents after failure of anti-tumour-necrosis-factor-(TNF)α agent in Crohn's disease (CD) is yet to be defined. AIMS To assess the effectiveness and safety of ustekinumab compared to vedolizumab as second-line treatment in CD patients who failed anti-TNFα therapy. METHODS Retrospective analysis of clinical response and remission at 14 and 52 weeks to ustekinumab by physician global assessment (PGA). A propensity score-matched analysis with a cohort treated with vedolizumab was performed. RESULTS Of 282 patients (mean age 40 ± 15, F:M ratio 1.7:1) treated with ustekinumab, clinical response or remission was reached by 200/282 patients (70.9%) at 14 weeks, and 162/259 patients (62.5%) at 52 weeks. Overall, 74 adverse events occurred, of which 26 were labelled as serious (8.3 per 100 person-year). After exclusion of patients without prior anti-TNFα exposure and patients previously exposed to vedolizumab or ustekinumab, we analysed 275/282 patients (97.5%) on ustekinumab and 118/135 patients (87.4%) on vedolizumab. Propensity score analysis revealed that at 14 weeks, patients treated with ustekinumab were 38% (95% CI 25%-50%; P < 0.001) more likely to achieve clinical remission, while at 52 weeks, the difference of 9% (95% CI -15% to 33%; P = 0.462) was not significant. CONCLUSIONS Ustekinumab was effective and well tolerated in this real-world cohort. While ustekinumab proved more effective at 14-weeks, we found no statistically significant differences at 52 weeks compared to vedolizumab.
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14
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Flanagan E, Prentice R, Wright EK, Gibson PR, Ross AL, Begun J, Sparrow MP, Goldberg R, Rosella O, Burns M, Kiburg KV, Bell SJ. Ustekinumab levels in pregnant women with inflammatory bowel disease and infants exposed in utero. Aliment Pharmacol Ther 2022; 55:700-704. [PMID: 34907546 DOI: 10.1111/apt.16739] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/03/2021] [Accepted: 12/08/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Ustekinumab is increasingly used in pregnant women with inflammatory bowel disease (IBD). Existing safety data are reassuring, but the stability of ustekinumab levels in pregnancy, degree of transfer to the infant and time to infant clearance are unknown. METHODS In this prospective observational study, ustekinumab-exposed women with IBD had trough levels measured in each trimester of pregnancy and at delivery. Infant ustekinumab levels were measured at delivery and ongoing until clearance was achieved. Trough ustekinumab level stability in individuals across pregnancy was compared by Skillings-Mack test. Spearman coefficients were used to correlate maternal and infant delivery levels, and median time to infant ustekinumab clearance was defined. RESULTS 19 pregnant women receiving ustekinumab were included. There was no difference in ustekinumab levels across pregnancy in those with two or more representative trough levels (P = 0.83, n = 11). Infant delivery ustekinumab levels were higher than maternal levels, with a median infant:maternal ratio of 1.79 (IQR 1.26-3.1). There was a positive correlation between maternal and infant delivery ustekinumab levels (r = 0.75, P = 0.001) and an inverse correlation between the number of days from final antenatal dose and delivery infant ustekinumab level (r = -0.65, P = 0.006). Median time of infant ustekinumab clearance was 9 (range 6-19) weeks (n = 9). CONCLUSION Ustekinumab drug levels appear stable in pregnancy, with a delivery infant:maternal ratio similar to that of anti-TNFs. Infant ustekinumab clearance was complete by 20 weeks post-partum, however, infants exposed in utero should avoid live vaccination before 12 months of age until further clearance data are obtained.
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Affiliation(s)
- Emma Flanagan
- Department of Gastroenterology, St Vincent's Hospital Melbourne Pty Ltd, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
| | - Ralley Prentice
- Department of Gastroenterology, St Vincent's Hospital Melbourne Pty Ltd, Melbourne, Australia
- Department of Gastroenterology, Monash Health, Melbourne, Australia
- Monash University, Clayton, Australia
| | - Emily K Wright
- Department of Gastroenterology, St Vincent's Hospital Melbourne Pty Ltd, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
| | - Peter R Gibson
- Department of Gastroenterology, Alfred Health, Melbourne, Australia
- Monash University, Clayton, Australia
| | - Alyson L Ross
- Department of Gastroenterology, St Vincent's Hospital Melbourne Pty Ltd, Melbourne, Australia
| | - Jakob Begun
- Department of Gastroenterology, Mater Hospital Brisbane, Brisbane, Australia
| | - Miles P Sparrow
- Department of Gastroenterology, Alfred Health, Melbourne, Australia
- Monash University, Clayton, Australia
| | - Rimma Goldberg
- Department of Gastroenterology, Monash Health, Melbourne, Australia
- Monash University, Clayton, Australia
| | - Ourania Rosella
- Department of Gastroenterology, Alfred Health, Melbourne, Australia
| | - Megan Burns
- Department of Gastroenterology, Monash Health, Melbourne, Australia
| | - Katerina V Kiburg
- Department of Medicine, St Vincent's Hospital Melbourne Pty Ltd, Melbourne, Australia
| | - Sally J Bell
- University of Melbourne, Melbourne, Australia
- Department of Gastroenterology, Monash Health, Melbourne, Australia
- Monash University, Clayton, Australia
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15
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Al-Janabi A, Yiu ZZN. Biologics in Psoriasis: Updated Perspectives on Long-Term Safety and Risk Management. Psoriasis (Auckl) 2022; 12:1-14. [PMID: 35024352 PMCID: PMC8747772 DOI: 10.2147/ptt.s328575] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 12/23/2021] [Indexed: 12/12/2022] Open
Abstract
Biologics targeting Th1/Th17 cytokines have revolutionised psoriasis treatment. In addition to treatment effectiveness, it is important to define and understand the long-term risks of biologic therapy in order to guide therapy selection and minimise these risks for patients where possible. This review article summarises available evidence from trial data, observational studies and pharmacovigilance registries to explore key long-term risks of biologic treatment, and how these risks might be managed in clinical practice.
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Affiliation(s)
- A Al-Janabi
- Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- The Dermatology Centre, Salford Royal NHS Foundation Trust, Manchester NIHR Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester, M6 8HD, UK
| | - Z Z N Yiu
- Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- The Dermatology Centre, Salford Royal NHS Foundation Trust, Manchester NIHR Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester, M6 8HD, UK
- Correspondence: ZZN Yiu Dermatology Centre, Salford Royal Hospital, Stott Lane, Manchester, M6 8HD, UK Email
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16
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Wang H, Chen F, Hu Y, Shen M. Adverse Pregnancy Outcomes Following Exposure to Biologics in Women With Crohn's Disease: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2021; 8:753088. [PMID: 34760901 PMCID: PMC8573108 DOI: 10.3389/fmed.2021.753088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 09/27/2021] [Indexed: 11/13/2022] Open
Abstract
Crohn's disease is a chronic disease, which commonly affects women during their reproductive years. Poorly treated Crohn's disease is associated with adverse pregnancy outcomes. Biologics, a group of therapeutic drugs targeting inflammatory mediators including anti-TNF, anti-integrins and anti-interleukins, are increasingly used in pregnant women with Crohn's disease, exposing both the women and their fetuses to treatment-related complications. At present, it is unclear which biologics are more superior. This study performed a systematic review and meta-analysis to assess the risk of adverse pregnancy outcomes in women with Crohn's disease after exposure to biologics. Bibliographic databases were searched from inception to May 2021. The outcomes of interest were preterm delivery, low birth weight, spontaneous abortion, and congenital abnormalities. A total of 11 studies comprised of 1,875 pregnancies among women with Crohn's disease were included. Of these, 1,162 received biologics and 713 received non-biologic therapy. During the remission phase of the disease, the use of biological therapy increased the risk of adverse pregnancy outcomes, of which anti-integrins were associated with a higher incidence of adverse pregnancy outcomes than anti-TNF and anti-interleukins. Systematic Review Registration: http://www.crd.york.ac.uk/PROSPERO, identifier: CRD42020191275.
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Affiliation(s)
- Han Wang
- Department of Gynecology and Obstetrics, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Fang Chen
- Department of Gastroenterology, Hangzhou Red Cross Hospital, Hangzhou, China
| | - Yue Hu
- Department of Gastroenterology, First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Mengdie Shen
- Department of Internal Medicine, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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17
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Sako M, Yoshimura N, Sonoda A, Okano S, Ueda M, Tezuka M, Mine M, Yamanishi S, Hashimoto K, Kobayashi K, Takazoe M, Fukata M. Safety Prediction of Infants Born to Mothers with Crohn's Disease Treated with Biological Agents in the Late Gestation Period. JOURNAL OF THE ANUS RECTUM AND COLON 2021; 5:426-432. [PMID: 34746508 PMCID: PMC8553350 DOI: 10.23922/jarc.2021-021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 07/15/2021] [Indexed: 01/15/2023]
Abstract
Objectives: Knowledge gaps exist in the use of biologics for pregnant patients with Crohn's disease (CD), especially the usage of ustekinumab (UST) and infliximab (IFX) infusion during the late gestation period. In this case series, we investigated perinatal and neonatal outcomes and pharmacokinetics of these biologics in pregnant CD patients. Methods: Pregnant CD patients under treatment with IFX or UST during January 2017 to December 2019 were monitored. Growth and development of their babies were followed up to six months. Drug concentrations were measured in maternal peripheral and cord blood at delivery and infants' blood at six months of age. Results: Four cases were kept IFX treatment until late gestation (median last dose: 31.2 weeks). One case received UST until 23 weeks of gestation. All cases were in clinical remission but moderately undernourished. Babies were delivered by cesarean section at full term without any complications or congenital abnormalities. No growth or developmental defects and no susceptibility to infections were observed by six months. However, two babies whose mothers received IFX after 30 weeks of gestation were detected IFX in their blood at six months of age (0.94 and 0.24 pg/ml). Concentrations of UST in maternal and cord blood were 267.7 and 756.5 ng/ml, respectively. UST was not detected in the infant at six months of age. Conclusions: Administration of UST or IFX to pregnant patients with CD is safe, particularly IFX to be given in the late gestation period. Understanding of the pharmacokinetics of biologics in maternal-infant interactions may improve the management of pregnant CD patients.
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Affiliation(s)
- Minako Sako
- Center for Inflammatory Bowel Disease, Tokyo Yamate Medical Center, Japan Community Healthcare Organization, Tokyo, Japan
| | - Naoki Yoshimura
- Center for Inflammatory Bowel Disease, Tokyo Yamate Medical Center, Japan Community Healthcare Organization, Tokyo, Japan
| | - Akira Sonoda
- Center for Inflammatory Bowel Disease, Tokyo Yamate Medical Center, Japan Community Healthcare Organization, Tokyo, Japan
| | - Soh Okano
- Center for Inflammatory Bowel Disease, Tokyo Yamate Medical Center, Japan Community Healthcare Organization, Tokyo, Japan
| | - Miki Ueda
- Department of Pediatrics, Tokyo Yamate Medical Center, Japan Community Healthcare Organization, Tokyo, Japan
| | - Maki Tezuka
- Department of Obstetrics and Gynecology, Tokyo Yamate Medical Center, Japan Community Healthcare Organization, Tokyo, Japan
| | - Makiko Mine
- Department of Pediatrics, Tokyo Yamate Medical Center, Japan Community Healthcare Organization, Tokyo, Japan
| | - Shingo Yamanishi
- Department of Pediatrics, Tokyo Yamate Medical Center, Japan Community Healthcare Organization, Tokyo, Japan
| | - Koichi Hashimoto
- Department of Obstetrics and Gynecology, Tokyo Yamate Medical Center, Japan Community Healthcare Organization, Tokyo, Japan
| | - Koichi Kobayashi
- Department of Obstetrics and Gynecology, Tokyo Yamate Medical Center, Japan Community Healthcare Organization, Tokyo, Japan
| | - Masakazu Takazoe
- Center for Inflammatory Bowel Disease, Tokyo Yamate Medical Center, Japan Community Healthcare Organization, Tokyo, Japan
| | - Masayuki Fukata
- Center for Inflammatory Bowel Disease, Tokyo Yamate Medical Center, Japan Community Healthcare Organization, Tokyo, Japan
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18
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Julsgaard M, Baumgart DC, Baunwall SMD, Hansen MM, Grosen A, Bibby BM, Uldbjerg N, Kjeldsen J, Sørensen HG, Larsen L, Wildt S, Weimers P, Haderslev KV, Vind I, Svenningsen L, Brynskov J, Lyhne S, Vestergaard T, Hvas CL, Kelsen J. Vedolizumab clearance in neonates, susceptibility to infections and developmental milestones: a prospective multicentre population-based cohort study. Aliment Pharmacol Ther 2021; 54:1320-1329. [PMID: 34472644 DOI: 10.1111/apt.16593] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/21/2021] [Accepted: 08/20/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Little is known about the consequences of intrauterine exposure to, and the post-natal clearance of, vedolizumab. AIMS To investigate the levels of vedolizumab in umbilical cord blood of newborns and rates of clearance after birth, as well as how these correlated with maternal drug levels, risk of infection and developmental milestones during the first year of life METHODS: Vedolizumab-treated pregnant women with inflammatory bowel disease were prospectively recruited from 12 hospitals in Denmark and Canada in 2016-2020. Demographics were collected from medical records. Infant developmental milestones were evaluated by the Ages and Stages Questionnaire (ASQ-3). Vedolizumab levels were measured at delivery and, in infants, every third month until clearance. Non-linear regression analysis was applied to estimate clearance. RESULTS In 50 vedolizumab-exposed pregnancies, we observed 43 (86%) live births, seven (14%) miscarriages, no congenital malformations and low risk of adverse pregnancy outcomes. Median infant:mother vedolizumab ratio at birth was 0.44 (95% confidence interval [CI], 0.32-0.56). The mean time to vedolizumab clearance in infants was 3.8 months (95% CI, 3.1-4.4). No infant had detectable levels of vedolizumab at 6 months of age. Developmental milestones at 12 months were normal or above average. Neither vedolizumab exposure in the third trimester (RR 0.54, 95% CI, 0.28-1.03) nor combination therapy with thiopurines (RR 1.29, 95% CI, 0.60-2.77) seemed to increase the risk of infections in the offspring. CONCLUSIONS Neonatal vedolizumab clearance following intrauterine exposure is rapid. Infant vedolizumab levels did not correlate with the risk of infections during the first year of life. Continuation of vedolizumab throughout pregnancy is safe.
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19
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Prentice RE, Wright EK, Flanagan E, Ross AL, Bell SJ. Vedolizumab safety in pregnancy: Extricating drug from disease-related effects. J Gastroenterol Hepatol 2021; 36:3247-3248. [PMID: 34330150 DOI: 10.1111/jgh.15636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 07/22/2021] [Indexed: 12/09/2022]
Affiliation(s)
- R E Prentice
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia.,Department of Gastroenterology, Monash Health, Clayton, Victoria, Australia.,Faculty of Medicine, Monash University, Clayton, Victoria, Australia
| | - E K Wright
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia.,Faculty of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - E Flanagan
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia.,Faculty of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - A L Ross
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - S J Bell
- Department of Gastroenterology, Monash Health, Clayton, Victoria, Australia.,Faculty of Medicine, Monash University, Clayton, Victoria, Australia.,Faculty of Medicine, University of Melbourne, Parkville, Victoria, Australia
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20
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Rong JM, Luo J, Huang Q, Miao YL. Individualized selection of biological agents in treatment of inflammatory bowel disease. Shijie Huaren Xiaohua Zazhi 2021; 29:893-900. [DOI: 10.11569/wcjd.v29.i15.893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Inflammatory bowel disease (IBD) is a chronic non-specific inflammatory disease that can affect the ileum, colon, rectum, and even the entire digestive tract. In recent 10 years, with the in-depth understanding of its pathological mechanisms, the development of new drugs has been accelerated, and more and more biological agents have begun to be widely used in the treatment of IBD. The emergence of biological agents has significance for the treatment of IBD. This article will discuss how to individualize the selection of biologics from three aspects: The mechanism of action and clinical application of different biological agents, risk weighing, and rescue treatment for failure of anti-TNF therapy.
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Affiliation(s)
- Jia-Mei Rong
- Department of Gastroenterology, The First Affiliated Hospital of Kunming Medical University, Kunming 650032, Yunnan Province, China
| | - Juan Luo
- Department of Gastroenterology, The First Affiliated Hospital of Kunming Medical University, Kunming 650032, Yunnan Province, China
| | - Qi Huang
- Department of Gastroenterology, The First Affiliated Hospital of Kunming Medical University, Kunming 650032, Yunnan Province, China
| | - Ying-Lei Miao
- Department of Gastroenterology, The First Affiliated Hospital of Kunming Medical University, Kunming 650032, Yunnan Province, China
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Guerrero Vinsard D, Kane SV. Biologics and pregnancy: a clinician's guide to the management of IBD in pregnant women. Expert Rev Gastroenterol Hepatol 2021; 15:633-641. [PMID: 33440996 DOI: 10.1080/17474124.2021.1876562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Women with inflammatory bowel disease (IBD) endorse a tremendous amount of concern about medication exposure during pregnancy and their effects on the fetus. Medical providers caring for this patient population should be well informed and feel comfortable counseling their patients for the best pregnancy outcome possible.Areas covered: It is of particular importance to understand the implications of use of biologics in preconception, pregnancy, and postpartum timeframes. Herein, we aim to inform the clinician about the impact of uncontrolled inflammation during pregnancy, the mechanisms of biologic transport through the placenta, the effects of biologics in maternal and neonatal outcomes, and additional postpartum considerations such as breastfeeding and vaccination safety.Expert opinion: The groundwork already set by previous research in terms of safety of biologic therapy during pregnancy has been reassuring. With the advent of more mechanisms of action but similar protein structure, i.e. they are IgG1 antibodies; the authors anticipate the recommendation of continuation of therapy throughout pregnancy will be sustained.
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Affiliation(s)
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, MN, USA
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