Outcomes out to 12 months after sequential use of high-dose tofacitinib following infliximab in acute severe ulcerative colitis

Small Molecules in the Treatment of Acute Severe Ulcerative Colitis: A Review of Current Evidence

Ulcerative colitis (UC) is an inflammatory bowel disease in which one-quarter of patients are at risk of developing a severe form of the disease known as acute severe UC (ASUC). This condition exposes patients to serious complications, including toxic megacolon, surgical intervention, and even death. The current therapeutic strategy relies on time-dependent, multi-step algorithms that integrate systemic corticosteroids, calcineurin inhibitors, and biologic agents (specifically infliximab) as medical therapy aimed at avoiding colectomy. Despite this approach, a significant proportion of patients fail to respond to either corticosteroids or infliximab and may require alternative therapeutic options if there is no urgent surgical necessity. These alternatives include other biologics or emerging small molecules, although the evidence supporting these treatments remains extremely low, even considering their well-documented and promising efficacy and safety in moderate-to-severe UC. Conversely, it is necessary to investigate whether infliximab can be effectively replaced or surpassed by other approved biological agents and small molecules as first-line therapy after steroid resistance. This review aims to summarise the available evidence on small molecules, specifically Janus kinase inhibitors and sphingosine-1-phosphate receptor modulators.

Upadacitinib as rescue therapy for corticosteroid failure acute severe ulcerative colitis: an Asian experience from Taiwan

PURPOSE

Acute severe ulcerative colitis (ASUC) is a medical emergent condition, and approximately one-third of patients with ASUC do not respond to corticosteroid. Whether small molecule drugs are efficient and safe for salvage therapy of ASUC is not well-understood.

METHODS

Consecutive patients with ASUC who failed responding to first-line corticosteroid were retrospectively enrolled. Clinical, laboratory, endoscopic, and pathological data were analyzed.

RESULTS

Five Asian male patients (median age of 38.9 years old) with ASUC who received salvage therapy with upadacitinib were enrolled. The mean (± standard deviation) disease duration was 3.44 (± 3.30, 0.53 ~ 7.88) years. Baseline Montreal disease extent, C-reactive protein, and erythrocyte sedimentation rate were four (80%) E3 and one (20%) E2 disease, 40.54 (± 74.26) mg/dl, and 24.50 (± 19.09) mm/h, respectively. Daily upadacitinib 45 mg was prescribed for 56 days in all patients. Clinical response, clinical remission, corticosteroid-free remission, and endoscopic improvement at weeks 8 and 12 were achieved in five (100%) and five (100%), four (80%) and five (100%), four (80%) and five (100%), and four (80%) and five (100%) patients, respectively. One (20%) patient achieved histo-endoscopic remission at week 24. None of them had re-hospitalization or colectomy during the follow-up period but one patient developed penile simplex-1 infection which resolved after topical antiviral ointment without upadacitinib discontinuation.

CONCLUSIONS

Upadacitinib is an efficient salvage therapy for patients with ASUC. Further investigations are essential to assess long-term durability, safety profile, and viability as a bridging regimen in the treatment of ASUC.

Janus kinase inhibitors in the management of acute severe ulcerative colitis: a comprehensive review

BACKGROUND

One-third of patients with acute severe ulcerative colitis (ASUC) are steroid-refractory. Cyclosporine and infliximab are currently the mainstays of salvage therapy. Janus kinase inhibitors (JAKi) could play a role in the treatment of ASUC.

AIM

To review the evidence on JAKi in the management of ASUC.

METHODS

We performed a bibliographic search to identify studies focusing on the treatment of ASUC with JAKi.

RESULTS

Potential advantages of JAKi for the management of ASUC include their oral administration, rapid onset of action, short half-life, lack of immunogenicity, and effectiveness in patients with prior biologic exposure. Thirty studies (including 373 patients) have evaluated the efficacy of tofacitinib in ASUC, with a response rate (avoidance of colectomy) ranging between 43% and 100%, with a weighted mean of 82%. Experience with upadacitinib is more limited (only 10 studies and 74 patients are available) but also encouraging: mean colectomy-free rate ranging between 67% and 100%, with a weighted mean of 79%. However, experience with filgotinib in ASUC is currently nonexistent. Regarding safety, the available data does not reveal any new safety concerns when JAKi are used in ASUC, although follow-up periods are still short.

CONCLUSION

JAKi seems to be a promising treatment option for ASUC, with both tofacitinib and upadacitinib achieving colectomy-free rates of approximately 80%. Further studies are essential to define whether JAKi can replace cyclosporine/infliximab as second-line therapy for the medical management of ASUC, or whether they can even be used as initial treatment in place of intravenous corticosteroids.

Filgotinib to Treat Acute Severe Refractory Ulcerative Colitis: A Case Report and Review of the Literature

Introduction

Acute severe ulcerative colitis (ASUC) is a serious complication affecting 9%-15% of patients with UC within 3 months of diagnosis and up to 28% of patients during the course of the disease. Despite the use of infliximab and calcineurin inhibitors, the rate of colectomy remains high both during the hospitalization and in the 5 years after an acute episode. We present a case of ASUC that was unresponsive to conventional therapies but was successfully treated with filgotinib.

Case Presentation

A 21-year-old male with a recent diagnosis of UC presented to our hospital with a severe flare. He received rescue therapy of high-dose intravenous steroids and 10 mg/kg infliximab. We observed little clinical and biochemical benefits. The patient declined the surgical option. Therefore, we decided to start a second rescue therapy with a new and rapid-acting Janus kinase inhibitor, filgotinib, due to its characteristics and pharmacokinetic profile of rapid absorption and metabolism. The patient showed an immediate clinical and biochemical response at 48 h, an endoscopic response at week 3, and an endoscopic remission at week 10. No recurrence was observed after 12 months of follow-up. The patient is in clinical remission with a good quality of life.

Conclusion

Filgotinib may be an effective second-line therapy in an emergency setting such as ASUC in patients unresponsive to conventional therapy.

Future of Acute Severe Ulcerative Colitis-A Narrative Review

While corticosteroids have led to significant reduction in ASUC mortality over the last few decades, they are associated with significant side effects and up to 30% of patients have steroid refractory ASUC, which means we require safer and better therapies for patients with ASUC. Several salvage therapies have been proposed in guidelines; however, we lack high quality head-to-head randomised controlled trials to assess effectiveness and safety of these agents. Furthermore, the role of newer novel agents in ASUC management is unclear. We aim to present an up to date review and envisage future treatment of ASUC without steroids based on current trials and data. In summary, we conclude that ASUC treatment still heavily relies on corticosteroids despite the side effect profile. While infliximab and cyclosporine have extensive data, there are no prospective studies comparing them with corticosteroids as initial therapy. Novel therapies open up the possibility of oral options but require prospective data before any conclusion can be made.

Defining management strategies for acute severe ulcerative colitis using predictive models: a simulation-modeling study

BACKGROUND/AIMS

Robust management algorithms are required to reduce the residual risk of colectomy in acute severe ulcerative colitis (ASUC) refractory to standard infliximab salvage therapy. The aim of this study was to evaluate the performance and benefits of alternative ASUC management strategies using simulated prediction models of varying accuracy.

METHODS

This was a simulation-based modeling study using a hypothetical cohort of 5,000 steroid-refractory ASUC patients receiving standard infliximab induction. Simulated predictive models were used to risk-stratify patients and escalate treatment in patients at high risk of failing standard infliximab induction. The main outcome of interest was colectomy by 3 months.

RESULTS

The 3-month colectomy rate in the base scenario where all 5,000 patients received standard infliximab induction was 23%. The best-performing management strategy assigned high-risk patients to sequential Janus kinase inhibitor inhibition and mediumrisk patients to accelerated infliximab induction. Using a 90% area under the curve (AUC) prediction model and optimistic treatment efficacy assumptions, this strategy reduced the 3-month colectomy rate to 8% (65% residual risk reduction). Using an 80% AUC prediction model with only modest treatment efficacy assumptions, the 3-month colectomy rate was reduced to 15% (35% residual risk reduction). Overall management strategy efficacy was highly dependent on predictive model accuracy and underlying treatment efficacy assumptions.

CONCLUSIONS

This is the first study to simulate predictive model-based management strategies in steroid-refractory ASUC and evaluate their effect on short-term colectomy rates. Future studies on predictive model development should incorporate simulation studies to better understand their expected benefit.

What to do when traditional rescue therapies fail in acute severe ulcerative colitis

Acute severe ulcerative colitis (ASUC) is a medical emergency that affects approximately 25% of patients with ulcerative colitis at some point in time in their lives. Outcomes of ASUC are highly variable. Approximately 30% of patients do not respond to corticosteroids and up to 50% of patients do not respond to rescue therapy (infliximab or cyclosporin) and require emergency colectomy. Data are emerging on infliximab dosing strategies, use of cyclosporin as a bridge to slower acting biologic agents and Janus kinase inhibition as primary and sequential therapy. In this review, we outline contemporary approaches to clinical management of ASUC in the setting of failure to respond to traditional rescue therapies.

Navigating treatment resistance: Janus kinase inhibitors for ulcerative colitis

The management of refractory ulcerative colitis (UC) and acute severe UC (ASUC) is challenging due to the lack of standardized approaches in cases resistant to multiple treatments. In this editorial, I investigate the efficacy and safety of Janus kinase inhibitors, particularly upadacitinib and tofacitinib, in controlling severe and refractory disease. I highlight a notable case report by Xu et al, which explores the case of a patient with primary nonresponse to two classes of biologics and two fecal microbiota transplants who exhibited a remarkable response to upadacitinib. Furthermore, I discuss the use of tofacitinib in refractory UC and ASUC, either as monotherapy or in combination with biologics, which has shown promising response rates. Additionally, emerging evidence of upadacitinib efficacy in ASUC is presented. Overall, these cases emphasize the complex nature of managing refractory ASUC and the potential of small-molecule therapies to achieve remission. Further research is needed to refine treatment strategies for patients with treatment-resistant UC.

Risk of dyslipidemia and major adverse cardiac events with tofacitinib versus adalimumab in rheumatoid arthritis: a real-world cohort study from 7580 patients

Objective

To compare the effects of tofacitinib and adalimumab on the risk of adverse lipidaemia outcomes in patients with newly diagnosed rheumatoid arthritis (RA).

Methods

Data of adult patients newly diagnosed with RA who were treated with tofacitinib or adalimumab at least twice during a 3-year period from 1 January 2018 to 31 December 2020, were enrolled in the TriNetX US Collaborative Network. Patient demographics, comorbidities, medications, and laboratory data were matched by propensity score at baseline. Outcome measurements include incidental risk of dyslipidemia, major adverse cardiac events (MACE) and all-cause mortality.

Results

A total of 7,580 newly diagnosed patients with RA (1998 receiving tofacitinib, 5,582 receiving adalimumab) were screened. After propensity score matching, the risk of dyslipidaemia outcomes were higher in the tofacitinib cohort, compared with adalimumab cohort (hazard ratio [HR] with 95% confidence interval [CI], 1.250 [1.076-1.453]). However, there is no statistically significant differences between two cohorts on MACE (HR, 0.995 [0.760-1.303]) and all-cause mortality (HR, 1.402 [0.887-2.215]).

Conclusion

Tofacitinib use in patients with RA may increase the risk of dyslipidaemia to some extent compared to adalimumab. However, there is no differences on MACE and all-cause mortality.

Upadacitinib in end stage renal disease: A case of acute severe ulcerative colitis

Recent data, indicating that inflammatory bowel disease (IBD) may be a risk factor for future chronic kidney disease, highlight the need to study the safety and clinical effectiveness of advanced IBD therapies in patients with end stage renal disease (ESRD), defined as an eGFR <15 mL/min/1.73m2. Upadacitinib, a selective oral Janus kinase (JAK) 1 inhibitor, has demonstrated efficacy in the management of moderate to severe ulcerative colitis. There is also emerging data indicating that JAK inhibition may be clinically effective in the setting of steroid-refractory acute severe ulcerative colitis (ASUC). There is, however, a lack of "real-world" data documenting the use of JAK inhibitors in patients with ESRD. Here, we report the use of upadacitinib in a patient with ESRD for the management of steroid-refractory ASUC, demonstrating, for the first time, the safe and clinically effective use of upadacitinib in this population.