Recomendaciones GETECCU-2005 para el uso de infliximab (Remicade®) en la enfermedad inflamatoria intestinal

Tuberculin skin testing in inflammatory bowel disease patients from an endemic area of Brazil

Objective

Inflammatory bowel disease (IBD) is a chronic disorder involving the gastrointestinal tract. Immunosuppressive drugs are usually prescribed to treat IBD patients, and this treatment can lead to tuberculosis reactivation. This paper aimed to analyze tuberculin skin test (TST) results in IBD patients at a reference center in Brazil.

Methods

We evaluated TST results in IBD patients using a cross-sectional study. We also analyzed the medical records of patients treated at a reference IBD outpatient unit where TST is routinely performed.

Results

We reviewed 119 medical records of 57 (47.9%) Crohn's disease (CD), 57 (47.9%) ulcerative colitis (UC) and 5 (4.2%) indeterminate colitis (IC) patients. The mean (SD) age was 43.5 (13.7) years old. TST was positive in 24 (20.2%) of the patients. TST was positive in 16/57 (28.1%) UC and 6/57 (10.5%) CD patients (prevalence ratio [PR] 2.7). Forty-one patients (34.5%) were taking immunosuppressive drugs (azathioprine or prednisone) at the time of the TST, and six of these patients (14.6%) had positive test results. Two patients using infliximab had negative TST results. Thirty-five of the 41 patients (85.4%) on immunosuppressive treatment were anergic compared with 73.1% (57/78) of the untreated patients (PR 1.2).

Conclusions

Patients with IBD have TST results similar to the general Brazilian population. Within the IBD population, CD patients have a lower frequency of TST positivity than UC patients.

Therapeutic guidelines on ulcerative colitis: a GRADE methodology based effort of GETECCU

BACKGROUND AND AIM

Evidence-based clinical guidelines on Ulcerative colitis (UC) have been developed through a consensus, while GRADE methodology is the current standard for guideline development. This is the first one based on GRADE methodology on UC.

METHODS

Following GRADE methodology, the Spanish Group of Ulcerative Colitis and Crohn's disease (GETECCU) have developed a guideline on UC treatment. After selection of relevant clinical scenarios, 32 clinical questions were chosen and recommendations were established.

RESULTS

In 2 questions no recommendation was possible. Twenty-two actions were recommended for, 14 strongly and 8 weakly. However, in 8 questions a recommendation against doing something was obtained, weak in 5 and strong in 3. The majority of recommendations were based on moderate quality evidence, and only 5 on high-quality evidence.

CONCLUSIONS

With GRADE methodology we find a clear recommendation on possible actions in most clinical decisions in UC treatment, but much more clinical high-quality research is needed.

Efficacy of infliximab rescue therapy in patients with chronic refractory pouchitis: a multicenter study

BACKGROUND

Despite medical therapy, 30% of patients with ulcerative colitis (UC) need to undergo surgery. Around 50% of patients with proctocolectomy with ileal pouch-anal anastomosis (IPAA) develop complications of the pouch. Clinical evidence for the use of infliximab (IFX) in refractory pouchitis is limited. The aim of this study was to report efficacy of IFX in these patients.

METHODS

A retrospective, multicenter study was designed. Patients older than 18 years with chronic refractory pouchitis treated with IFX (5 mg/kg) were included. Short-term IFX efficacy was evaluated at week 8 and mid-term efficacy at weeks 26 and 52. Complete response was defined as cessation of diarrhea and urgency and partial response as marked clinical improvement but persisting symptoms. The modified Pouchitis Disease Activity Index (mPDAI) without endoscopy was calculated when available.

RESULTS

Thirty-three consecutive UC patients with chronic refractory pouchitis were included (18 male, mean age 45 years, range 21-67). At week 8, 21% patients achieved complete response and 63% showed partial clinical response. At weeks 26 and 52, 33% and 27% achieved complete response and 33% and 18% showed partial clinical response, respectively. Thirteen patients (39%) withdrew treatment (four for lack of efficacy, four for loss of response and five for adverse events). None of the potential factors analyzed had an influence on response to IFX.

CONCLUSIONS

IFX was effective in the short- and mid-term in patients with chronic refractory pouchitis. However, medication had to be discontinued in a high number of patients.

[Must immunomodulators be added to biological treatment in inflammatory bowel disease?]

Both biological agents and immunosuppressants are standard treatments in inflammatory bowel disease (IBD) and are frequently used in combination. Although this combination can increase therapeutic efficacy and help to prevent immunogenicity, concerns about the risk of adverse effects - particularly lymphoma - have been raised. IBD are obviously highly complex diseases, with many possible clinical scenarios, and there is no a universal treatment applicable to all patients. In this report we address this issue in a narrative review consisting of three parts. First, we provide a historical overview of the use of immunosuppressants and biological agents in IBD. Secondly, we review the available evidence, with both efficacy and safety considered in separate analyses. Thirdly, we propose different ways of using these drugs in the distinct clinical scenarios, both in Crohn's disease and in ulcerative colitis. Although the evidence is thoroughly reviewed, the main perspective is that of the practicing clinician.

[Infliximab therapy for inflammatory bowel disease: seven years on]

INTRODUCTION

The aim of this study was to describe the clinical experience of our center of the use of infliximab in pediatric patients with inflammatory bowel disease.

MATERIAL AND METHODS

We retrospectively reviewed all infliximab infusions administered in the Pediatric Gastroenterology Unit from October of 1999 to October of 2006. Fourteen patients (nine with Crohn's disease, three with ulcerative colitis, and two with indeterminate colitis) with a mean age of 9.6 years at diagnosis were treated with infliximab. Seventy-seven infusions were administered.

RESULTS

Efficacy was analyzed according to inflammatory bowel disease. Crohn's disease: in severe cases (PCDAI > 30), clinical remission (PCDAI < 10) was obtained in 80 % of the patients at week 10, decreasing to 60 % at week 54. Corticosteroid therapy could be reduced in 89 % of the patients and was discontinued in 55.5 %. Ulcerative colitis: clinical remission (modified Truelove-Witts index < 10) was initially obtained in 100 % of the patients but only 33 % were still in clinical remission at the end of the study. In the two corticosteroid-dependent patients, corticosteroid therapy could be reduced and even discontinued in one (50 %). Indeterminate colitis: neither of the two patients achieved clinical remission. The most frequent adverse effects observed were acute infusional reactions (42.8 % of the patients and 10.3 % of infusions), one of which was severe, and infections (28.6 % of patients), one of which (ileal abscess) required surgery.

CONCLUSIONS

The efficacy of infliximab seems to differ considerably in the distinct types of inflammatory bowel disease and is practically null in indeterminate colitis. Randomized controlled studies in children are required to assess the exact efficacy of infliximab in our patients.

[Current status of treatment of inflammatory bowel disease]

Inflammatory bowel disease encompasses a group of diseases with poorly defined etiology that affect the digestive tract. These diseases are characterized by their chronic course and by periods of disease activity, of variable severity, that alternate with periods of clinical remission. In the last few years, inflammatory bowel disease has been the object of intense research, which has increased knowledge of the physiopathogenic mechanisms involved. This has enabled the development of a new generation of biotechnological drugs effective in patients previously considered to be refractory to medical treatment and has allowed the accumulated corticosteroid dose to be reduced and the indications for surgery and hospital admissions to be decreased, thus improving quality of life. In addition, some classical drugs have been demonstrated to be effective in recurrence prevention after surgery for Crohn's disease and in the prevention of dysplasia and colorectal cancer in inflammatory bowel disease.

[Role of biological markers in inflammatory bowel disease]

The role played by the distinct biological markers in chronic inflammatory bowel disease (IBD) remains insufficiently characterized. C-reactive protein (CRP) has a short half-life and consequently it is elevated early after the onset of the inflammatory process and rapidly decreases after its resolution, making it an attractive marker of disease activity. Moreover, this test is inexpensive and easy to perform and is unaffected by medication. While Crohn's disease is associated with a marked CRP response, there is little or no elevation in the synthesis of this protein in ulcerative colitis. Erythrocyte sedimentation rate provides some advantages such as its ease of determination, availability, and reduced cost. Nevertheless, it also has several disadvantages, notably the fact that its concentration depends on age, the presence of anemia, smoking, and the use of certain drugs. Moreover, its utility is limited by its long half life and consequent prolonged latency period after changes in chronic IBD activity. In theory, fecal markers have the advantages of showing greater specificity in the diagnosis of chronic IBD. Several gastrointestinal diseases, including chronic IBD, show greater leukocyte elimination in feces and a close correlation has been described between fecal calprotectin concentration and leukocyte excretion quantified by 111indium. Advantages of this fecal marker are that it can be detected through a simple and inexpensive technique and also shows excellent stability in feces for prolonged periods. Like calprotectin, fecal lactoferrin is also quantified by a simple and inexpensive ELISA method, although there is considerably less experience with this latter marker.

[Monitoring of thiopurine methyltransferase and thiopurine metabolites to optimize azathioprine therapy in inflammatory bowel disease]

Determination of the activity of thiopurine methyltransferase (TPMT) and of thiopurine metabolites (6-thioguanine and 6-methylmercaptopurine nucleotides) could be useful for individualized monitoring of azathioprine (AZA) and 6-mercaptopurine (6-MP) doses. TPMT activity in the general population follows a trimodal distribution, in which approximately 0.3% of the population is homozygotic for the low-activity allele. A notable correlation has been observed between the low TPMP activity genotype or phenotype and the risk of myelotoxicity. Patients with a high TPMT activity genotype or homozygous phenotype should receive immunosuppressive doses that have clearly been demonstrated to be effective. In contrast, in patients with a low TPMT activity genotype or homozygous phenotype, the use of AZA/6-MP should be contraindicated or only very small doses should be administered. Importantly, TPMP deficiency explains only some cases of myelotoxicity and consequently periodic laboratory testing should be performed in patients receiving AZA/6-MP, even though TPMP function may be normal. Currently, the utility of routine thiopurine metabolite determinations in patients undergoing AZA/6-MP therapy has not been established and this practice should be limited to specific situations such as lack of response to thiopurine therapy or the occurrence of thiopurine-related adverse effects. Randomized trials comparing the routine strategy of AZA/6-MP dosing (based exclusively on the patient's weight) versus individualized monitoring (based on quantification of TPMP activity and/or thiopurine metabolites) are required before definitive conclusions on the most effective alternative can be drawn.