Thalidomide in gastrointestinal disorders

Treatment of recurrent aphthous stomatitis (RAS; aphthae; canker sores) with a barrier forming mouth rinse or topical gel formulation containing hyaluronic acid: a retrospective clinical study

BACKGROUND

Use of hyaluronic acid-based products has become a valuable alternative to drug-based approaches in the treatment of recurrent aphthous stomatitis (RAS). The presented study aimed to investigate the effect of a barrier forming hyaluronic acid containing mouth wash or a topical gel formulation on the healing of RAS and patient's quality of life.

METHODS

For this single-center retrospective study, medical records of the Dental School of the University of Brescia were screened for adult and systemically health patients suffering from minor recurrent aphthous stomatitis (RAS) and treated with either a barrier forming, hyaluronic acid containing mouth wash (GUM® AftaClear® rinse) or a topical gel (GUM® AftaClear® gel) in 2015. All patients fulfilling the in-/exclusion criteria and presenting full data sets on lesion diameter, lesion color, as well as pain perception for baseline (day 0) and 4 and 7 days after treatment were enrolled into the presented study.

RESULTS

Out of 60 screened patients, a total of 20 patients treated with the Rinse formulation and 25 treated with the Gel formulation were eligible for the enrollment into this study. Both groups showed equal distribution in patient's age, sex and presented a similar mean lesion size (3.0 ± 1.0 mm), lesion color distribution as well as pain perception at baseline. All patients showed significant normalization of lesion color, reduction of pain, and lesion dimension within the course of their treatment. After 7 days, the mean percentage of lesion reduction was highly significant for both groups attaining 77.4 ± 30.1% in the Rinse group and 81.2 ± 23.1% in the Gel group with a complete lesion closure obtained in 60 and 56% of the cases, respectively. However, a significant (p < 0.05) higher percentage of lesions in the Gel group (72%) compared to the Rinse group (40%) showed an improvement in lesion size already after 3 days.

CONCLUSIONS

Within the limitation of retrospective design, it can be concluded that both the barrier forming hyaluronic acid containing mouth rinse as well as the topical gel formulation are effective in the treatment of minor recurrent aphthous stomatitis (RAS), with a trend for an earlier healing onset for the topical Gel formulation.

Endoscopic and Histologic Healing in Children With Inflammatory Bowel Diseases Treated With Thalidomide

BACKGROUND & AIMS

Mucosal healing, determined by endoscopic evaluation, is one of the most important prognostic markers for patients with inflammatory bowel diseases. Findings from histologic evaluation, however, could complement findings from endoscopy in assessing mucosal responses to treatment. We analyzed long-term results of children treated with thalidomide to determine the association between clinical response and histology and endoscopy findings.

METHODS

We collected data from 2 multicenter trials of 70 children with refractory Crohn's disease (CD) or ulcerative colitis (UC) (2-18 years old; ileocolonic or colonic disease) given thalidomide or placebo (NCT00720538). Clinical remission and clinical response at 8 weeks were defined as a pediatric CD activity index scores 10 points or lower and a decrease of at least 50% from baseline, respectively, for patients with CD; and as a pediatric UC activity index score below 10 and a decrease of at least 20 points from baseline, respectively, for patients with UC. Patients with a clinical response to 8 weeks' treatment with thalidomide underwent endoscopic examination with biopsy collection at study weeks 12 and 52. Severity of inflammation in patients with UC was assessed by Mayo score and in patients with CD by 4-grade system. Biopsies were assessed for signs of active inflammation, erosion or ulceration, and crypt abscesses and assigned a histologic score.

RESULTS

Clinical remission was observed in 42 patients (60.0%) and clinical response in 45 patients (64.2%) at Week 8. At Week 52, a total of 38 patients (54.3%) were still in clinical remission or still had a clinical response; 29 patients (41.4%) had mucosal healing, defined as complete healing of erosions or ulcerations, and 20 patients (27.7%) had histologic healing, defined as complete absence of markers of inflammation. Of patients with clinical remission or clinical response, 75.3% also had mucosal healing and 52.6% also had histologic healing. The probability of achieving mucosal healing decreased significantly with increasing values of erythrocyte sedimentation rate (adjusted odds ratio, 0.96; 95% CI, 0.93-0.98; P = .006).

CONCLUSIONS

In a long-term analysis of data from 2 clinical trials of pediatric patients with CD or UC, 52 weeks' treatment with thalidomide led to clinical remission in 54.3% of patients with ileocolonic or colonic disease; of these patients, 75.3% had mucosal healing and 52.6% also had histologic healing. Further studies are needed to determine how thalidomide therapy affects long-term progression of inflammatory bowel diseases. (ClinicalTrials.gov number NCT00720538).

Peripheral neuropathy: an underreported neurologic manifestation of inflammatory bowel disease

BACKGROUND AND AIMS

One of the most frequent neurologic complications reported in inflammatory bowel disease population is peripheral neuropathy; however, clinical aspects of peripheral nerve damage are not well characterized. The aim of the review is to present the existing literature on peripheral neuropathy in inflammatory bowel disease patients.

METHODS

A literature search identified the publications reporting on epidemiology, clinical features, underlying mechanisms and management of ulcerative colitis and Crohn's disease patients with peripheral nerve involvement.

RESULTS

The pathogenesis of peripheral nervous system damage in inflammatory bowel disease has yet to be elucidated, although it seems to be related to immune mechanisms; therefore, treatment with immunotherapy is recommended. In addition, peripheral neuropathy may appear as iatrogenic-related disorders associated with several drugs used in controlling inflammatory bowel disease activity; finally, peripheral neuropathy may also be caused by micronutrient deficiencies secondary to malabsorption-related disorders.

CONCLUSIONS

Although peripheral nervous nerve damage associated with inflammatory bowel disease is rarely reported, clinicians should be aware of the peripheral neuropathy clinical manifestations in order to recognize it and provide early treatment, which is crucial for preventing major neurologic morbidity. Heightened awareness is necessary for the successful management of these patients.

Systematic review: thalidomide and thalidomide analogues for treatment of inflammatory bowel disease

BACKGROUND

It has been reported that thalidomide may be effective in treating inflammatory bowel disease (IBD).

AIM

To review the evidence examining the efficacy and safety of thalidomide for inducing and maintaining remission in Crohn's disease (CD) and ulcerative colitis (UC).

METHODS

The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PubMed (1950-August 2014), EMBASE (1984-August 2014), Scopus, and Web of knowledge were searched for randomised controlled trials (RCTs), observational studies and case series. The primary outcomes were induction of remission or response for active IBD or relapse rate for patients in remission and subsequently on thalidomide/analogues for at least 3 months.

RESULTS

Twelve studies (2 RCTs and 10 case series) met the inclusion criteria for inducing remission and included 248 patients (10 with UC, 238 with CD). Only one RCT of paediatric CD achieved high quality scores (remission rate thalidomide: 46%, placebo: 12%; p=0.01). The crude pooled remission rate for thalidomide was 49% and 25% in luminal and perianal CD respectively. For UC, 50% achieved remission and 10% had partial response. One case series reported 21 patients (17 CD, four UC) who maintained remission for 6 months. Many adverse events were reported including sedation (32%) and peripheral neuropathy (20%).

CONCLUSIONS

One high quality RCT showed that thalidomide is effective for inducing remission in paediatric CD. The current evidence is insufficient to support using thalidomide to induce remission in UC or adult CD, or to maintain remission in IBD. Significant adverse events may occur, necessitating discontinuation of thalidomide.

The clinical implications of thalidomide in inflammatory bowel diseases

Thalidomide has anti-inflammatory and anti-angiogenetic activity that makes it suitable for treating inflammatory bowel diseases (IBD). The recent guidelines from the European Crohn's and Colitis Organization/European Society for Pediatric Gastroenterology Hepatology and Nutrition conclude that thalidomide cannot be recommended in refractory pediatric Crohn's disease but that it may be considered in selected cohorts of patients who are not anti-TNFα agent responders. The main adverse effect is the potential teratogenicity that renders the long-term use of thalidomide problematic in young adults due to the strict need for contraceptive use. In short-term use it is relatively safe; the most likely adverse effect is the neuropathy, which is highly reversible in children. So far the use of thalidomide is reported in 223 adult and pediatric IBD patients (206 with Crohn's disease). In the following sections, the authors will discuss efficacy and safety of thalidomide, in the short-term treatment of IBD.

Imidazolium-derived ionic salts induce inhibition of cancerous cell growth through apoptosis

A study of the effects of imidazolium-based ionic liquids on 60 human cancer cell lines representing diverse histologies has identified four compounds which show potency at a nanomolar dose.

Thalidomide use and outcomes in pediatric patients with Crohn disease refractory to infliximab and adalimumab

OBJECTIVE

The aim of the study was to evaluate thalidomide as rescue therapy for pediatric patients with severe refractory Crohn disease (CD) who failed to respond to antitumor necrosis factor (TNF) biologic agents.

PATIENTS AND METHODS

A computerized database was used to identify children with CD who had failed conventional immunosuppression therapy and received thalidomide rescue therapy. Twelve patients, mean age at diagnosis 10 years, were identified. Eight children had disease localized to the ileum and colon and 4 to the gastroduodenal area and colon. Five cases were complicated by strictures and 7 by fistulae. Previous drug therapy included azathioprine/6-mercaptopurine (11/12), methotrexate (7/12), and anti-TNF biologics (12/12). Outcome measures were Harvey-Bradshaw Index, change in prednisone dose, hospitalizations, bowel resections, and incision and drainage procedures. Laboratory evaluations were calculated before and after 1 to 6 months of thalidomide.

RESULTS

Mean Harvey-Bradshaw Index score improved from 11.8 to 3.9 (P = 0.0004), mean prednisone dose decreased from 13.9 to 2.3  mg/day (P = 0.001), mean number of hospitalizations decreased from 6.3 to 1.3 (P = 0.002), and erythrocyte sedimentation rate decreased from 35 to 14  mm/h (P = 0.02). The surgery rate pre-thalidomide was 0.031 and on thalidomide was 0.004. Of the 7 patients with fistulae, 5 had complete fistula closure, 1 had partial closure, and 1 showed no improvement. Adverse reactions that resulted in discontinuation of thalidomide are as follows: 42% peripheral neuropathy, 17% worsening of the CD, 8% dizziness, and 8% allergic reaction. All 5 patients who developed peripheral neuropathy had clinical resolution of the neurologic symptoms within 2 to 3 months after stopping thalidomide.

CONCLUSIONS

Thalidomide is a potentially effective rescue therapy for severe refractory CD in children who fail to respond to anti-TNF medications.

Thalidomide induces mucosal healing in Crohn's disease: case report

Crohn's disease is a chronic inflammatory disorder of the gastrointestinal tract that is defined by relapsing and remitting episodes. Tumor necrosis factor alpha (TNF-α) appears to play a central role in the pathophysiology of the disease. Standard therapies for inflammatory bowel disease fail to induce remission in about 30% of patients. Biological therapies have been associated with an increased incidence of infections, especially infection by Mycobacterium tuberculosis (Mtb). Thalidomide is an oral immunomodulatory agent with anti-TNF-α properties. Recent studies have suggested that thalidomide is effective in refractory luminal and fistulizing Crohn's disease. Thalidomide costimulates T lymphocytes, with greater effect on CD8+ than on CD4+ T cells, which contributes to the protective immune response to Mtb infection. We present a case of Crohn's disease with gastric, ileal, colon and rectum involvement as well as steroid dependency, which progressed with loss of response to infliximab after three years of therapy. The thorax computed tomography scan demonstrated a pulmonary nodule suspected to be Mtb infection. The patient was started on thalidomide therapy and exhibited an excellent response.

Thalidomide in luminal and fistulizing Crohn's disease resistant to standard therapies

BACKGROUND

Thalidomide has been shown to be an effective treatment in Crohn's disease.

AIM

To assess the efficacy and tolerability of thalidomide in refractory Crohn's disease patients.

METHODS

Twenty-five patients were treated. Retrospective 'estimated' Crohn's Disease Activity Indices were assessed at baseline and at the end of follow-up. Clinical response was defined as symptomatic improvement and a reduction in the 'estimated' Crohn's Disease Activity Index of >100 points, > or =50% reduction in draining fistulas or clinical improvement in perianal ulcers. Clinical remission was defined as symptom resolution and an 'estimated' Crohn's Disease Activity Index <150, complete fistula closure or complete ulcer healing.

RESULTS

Six of eight patients treated for luminal disease responded to thalidomide at a median follow-up of 12 months (three clinical responses, three clinical remissions). The median reduction in 'estimated' Crohn's Disease Activity Index was 212 points (P = 0.005). Nine of 11 patients with active fistulizing disease responded to thalidomide (six responses; three remissions). The four patients treated for both luminal and fistulizing disease had fistula response. Three of them had a response in luminal disease activity. One of two patients with ulcerating perianal disease responded. Twelve patients discontinued treatment because of adverse effects (three sedation; two abdominal pain; one leucopoenia; six neuropathy).

CONCLUSION

Thalidomide is an effective short- to medium-term treatment in selected patients with refractory luminal and fistulizing Crohn's disease. Its long-term use is limited by toxicity.

Medical therapy for refractory pediatric Crohn's disease

Crohn's disease is a common indication for referral to pediatric gastroenterology. While most patients with Crohn's disease respond to standard induction therapy, steroid-refractory or steroid-dependent disease is a frequently encountered problem. This review discusses the data existing in both the adult and pediatric literature for medical therapy of refractory pediatric Crohn's disease.

Treatment of fistulizing Crohn's disease

The primary goals of the clinician in the treatment of fistulizing Crohn's disease (CD) include (1) defining the anatomy of the fistula, (2) draining any associated infectious material, (3) eradicating the fistulous tract through medical or surgical therapies, and (4) preventing recurrence of fistulas. Evaluation and therapeutic decisions require close collaboration between the gastroenterologist and surgeon. Appropriate evaluation should include identification of septic complications, delineation of the fistulous tract including the origin and terminus of the fistula, and determination of the extent of bowel involvement with active CD. Drainage of abscesses and control of septic complications through the placement of drains or setons is essential. Conservative therapy with avoidance of sphincter muscle-cutting procedures is the standard approach. The appropriate approach to asymptomatic patients is uncertain because there are little data to indicate if treatment alters the natural course of disease.

Preconception health counseling for women exposed to teratogens: the role of the nurse

Women with unintended pregnancies who are exposed to teratogens constitute the highest risk group for fetal harm. Teratogen exposures come from substances, medications, chronic and acute diseases, and environmental factors. Nurses play a critical role in reducing unintended pregnancy and promoting preconception health. A greater understanding of the role of teratogens and strategies to improve history taking and help women prevent unintended pregnancy will improve nurses' ability to reduce teratogen exposure in women at risk.

[Lung toxicity due to thalidomide]

Although the side effects of thalidomide are well known, lung toxicity has not been reported. We describe the case of a 65-year-old man with multiple myeloma (IgG kappa) in stage IA who, on the thirty-seventh day of treatment with thalidomide, developed acute coughing, general malaise, dyspnea at rest and sudoresis. Blood pressure was 90/60 mm Hg and temperature was normal. An interstitial and alveolar pattern was visible on the right side of a chest film and arterial blood gases indicated partial respiratory insufficiency (pH 7.40, PaCO2 40 mmHg, PaO2 47 mmHg). Blood analysis showed alterations expected for multiple myeloma and microbiology was negative (sputum and blood cultures and urinary antigen detection for Streptococcus pneumoniae and Legionella pneumophila). After thalidomide was withdrawn and oxygen and intravenous corticoids were administered, outcome was good. A chest film 4 days later was normal and arterial blood gases showed that respiratory insufficiency had disappeared. We conclude that severe lung toxicity should be included among the potential adverse effects of thalidomide.

Thalidomide: new indications?

Thalidomide, which was developed as a nonbarbiturate sedative agent, was taken off the market in 1961 after it was linked to a spate of major birth defects. Gradually, thalidomide was reintroduced for the treatment of a few skin diseases including leprous erythema nodosum, severe mucosal ulcers (e.g., associated with HIV infection or Behçet's disease), lymphocytic skin infiltrations, cutaneous lupus erythematosus, and chronic graft-versus-host disease. Recent reports of original pharmacological properties including modulation of cytokine production (mainly reduced TNF-alpha production) and inhibition of angiogenesis have led to the suggestion that thalidomide may be useful in some inflammatory and neoplastic conditions. Several open-label studies and case reports have described the effects of thalidomide in Crohn's disease, rheumatoid arthritis, ankylosing spondylarthritis, systemic sclerosis, and a few other systemic disorders. In these indications, minor but dose-limiting side effects were apparently common. Thalidomide analogs with better acceptability profiles are under evaluation. The anti-angiogenic effects of thalidomide may make this compound valuable as single-drug therapy or as an adjunct to chemotherapy in patients with cancer, particularly those with metastases or multiple myeloma. This possibility requires further evaluation.