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Cai X, Wu W, Guo G, Chen J, Xu J, Lin W, Huang P, Lin C, Lin R. Physiologically-based pharmacokinetic modeling to predict the exposure and provide dosage regimens of Ustekinumab in pediatric patients with inflammatory bowel disease. Eur J Pharm Sci 2024; 199:106807. [PMID: 38797440 DOI: 10.1016/j.ejps.2024.106807] [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: 02/01/2024] [Revised: 04/08/2024] [Accepted: 05/21/2024] [Indexed: 05/29/2024]
Abstract
Ustekinumab (UST), a fully human immunoglobulin G1 κ monoclonal antibody, exhibiting high affinity for the p40 subunit shared by IL-12 and IL-23, which play key roles in the pathogenesis of inflammatory bowel disease (IBD). By scaling the physiologically-based pharmacokinetic modeling (PBPK) model of UST in adult patients with IBD, we aim to predict effective dosages for UST in pediatric patients, thereby offering a more practical dosing regimen for real-world applications. In this work, a PBPK model for UST in adult patients with IBD has been developed using PK-Sim and Mobi. Advanced ontogeny model has been incorporated to extrapolate the model to pediatric patients. The simulation results showed that the fold errors of the predicted and observed values of the area under the curve (AUC) and peak plasma concentration (Cmax) were between 0.79 and 1.73. For children aged 6-18, it is recommended to administer the drug per kilogram of body weight, at the model-recommended dose, to achieve a median AUC similar to that of the adult reference population post-administration. This comprehensive model construction enables us to comprehensively and extensively explore the pharmacokinetic characteristics of UST in pediatric patients of different age groups, providing robust support for clinical applications and personalized drug therapy.
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Affiliation(s)
- Xiaoxi Cai
- Department of Pharmacy, the First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, PR China; Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, PR China
| | - Wanhong Wu
- Department of Pharmacy, the First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, PR China; Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, PR China
| | - Guimu Guo
- Department of Pharmacy, the First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, PR China; Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, PR China
| | - Jiarui Chen
- Department of Pharmacy, the First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, PR China; Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, PR China
| | - Jianwen Xu
- Department of Pharmacy, the First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, PR China; Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, PR China
| | - WeiWei Lin
- Department of Pharmacy, the First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, PR China; Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, PR China
| | - Pinfang Huang
- Department of Pharmacy, the First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, PR China; Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, PR China
| | - Cuihong Lin
- Department of Pharmacy, the First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, PR China; Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, PR China
| | - Rongfang Lin
- Department of Pharmacy, the First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, PR China; Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, PR China.
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McDonald C, Kerr H, Gibbons E, Lukose T, Cheriyan D, Harewood G, Patchett S, O’Toole A, Kelly O, Boland K. Higher Ustekinumab Levels in Maintenance Therapy are Associated with Greater Mucosal Healing and Mucosal Response in Crohn's Disease: An Experience of 2 IBD Centers. Inflamm Bowel Dis 2024; 30:423-428. [PMID: 37158577 PMCID: PMC10906356 DOI: 10.1093/ibd/izad073] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Indexed: 05/10/2023]
Abstract
BACKGROUND Ustekinumab (UST), a human monoclonal antibody that binds the p40 subunit of interleukin 12 (IL-12) and IL-23, is licensed for induction and maintenance therapy of moderate to severe inflammatory bowel disease (IBD). To date, there is limited data published on any potential association between ustekinumab serum trough levels and mucosal healing in order to guide treatment strategies and appropriate dosing. AIM This study aims to identify a relationship between maintenance ustekinumab serum trough levels and mucosal healing and/or response in patients with Crohn's disease in an observational cohort study. METHODS Ustekinumab serum trough levels and antibody titres were analyzed in patients on maintenance drug using an ELISA drug-tolerant assay. Mucosal response (MR) was defined as ≥50% reduction in fecal calprotectin level (FC) and/or ≥50% reduction in the Simple Endoscopic Score for Crohn's Disease (SES-CD score). Mucosal healing (MH) was defined as FC ≤150 µg/mL and/or global SES-CD score ≤5. Median trough levels were analyzed using the Kruskal-Wallis test, and logistic regression was used to determine sensitivity and specificity of levels predicting mucosal response. RESULTS Forty-seven patients on maintenance ustekinumab for Crohn's disease were included in this study. The majority were female (66%), with a median age of 40 years (21-78 years). The majority of patients were biologic-experienced (89.4%, n = 42). Patients with histologically confirmed Crohn's disease represented 100% (n = 47) of the cohort. Over one-third of patients (n = 18, 38.3%) were on higher than standard dosing of 90 mg every 8 weeks. Patients with mucosal healing (n = 30) had significantly higher mean serum ustekinumab levels (5.7 µg/mL, SD 6.4) compared with those with no response (1.1 µg/mL, SD 0.52; n = 7, P < .0001). A serum ustekinumab trough level greater than 2.3 µg/mL was associated with MH, with a sensitivity of 100% and specificity of 90.6% (likelihood ratio 10.7). Similarly, for patients with MR (n = 40), we observed a higher mean serum ustekinumab trough level (5.1 µg/mL, SD 6.1) compared with those with no response (1.1 µg/mL, SD 0.52; n = 7, P < .0001). Furthermore, a serum ustekinumab trough level greater than 2.3 µg/mL was associated with a 10-fold increased likelihood of mucosal response vs mucosal nonresponse (sensitivity 100%, specificity 90.5%, likelihood ratio 10.5). CONCLUSION This study demonstrates that higher ustekinumab serum trough levels are associated with a greater likelihood of achieving mucosal healing and mucosal response in patients with Crohn's disease regardless of prior biologic exposure. Further prospective studies are required to correlate target maintenance trough levels and the optimal time to dose-escalate in order to improve patient outcomes.
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Affiliation(s)
- Ciarán McDonald
- Department of Gastroenterology, Beaumont Hospital, RCSI Hospital Group, Dublin 9, Ireland
| | - Hilary Kerr
- Department of Gastroenterology, James Connolly Hospital, RCSI Hospital Group, Dublin 15, Ireland
| | - Eimear Gibbons
- Department of Gastroenterology, James Connolly Hospital, RCSI Hospital Group, Dublin 15, Ireland
| | - Tincymol Lukose
- Department of Gastroenterology, Beaumont Hospital, RCSI Hospital Group, Dublin 9, Ireland
| | - Danny Cheriyan
- Department of Gastroenterology, Beaumont Hospital, RCSI Hospital Group, Dublin 9, Ireland
| | - Gavin Harewood
- Department of Gastroenterology, Beaumont Hospital, RCSI Hospital Group, Dublin 9, Ireland
| | - Stephen Patchett
- Department of Gastroenterology, Beaumont Hospital, RCSI Hospital Group, Dublin 9, Ireland
| | - Aoibhlinn O’Toole
- Department of Gastroenterology, Beaumont Hospital, RCSI Hospital Group, Dublin 9, Ireland
| | - Orlaith Kelly
- Department of Gastroenterology, James Connolly Hospital, RCSI Hospital Group, Dublin 15, Ireland
| | - Karen Boland
- Department of Gastroenterology, Beaumont Hospital, RCSI Hospital Group, Dublin 9, Ireland
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Okamoto H, Tanaka Y, Shibagaki Y, Kuronuma S, Miyatani Y, Umeda S, Mishiro-Sato E, Takeuchi O, Hattori S, Kobayashi T, Okuwaki M. Measurement of the intracellular active metabolites of thiopurine drugs to evaluate the enzymatic activity of nudix hydrolase 15 in human blood samples. J Chromatogr B Analyt Technol Biomed Life Sci 2024; 1234:123993. [PMID: 38246006 DOI: 10.1016/j.jchromb.2024.123993] [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: 04/07/2023] [Revised: 12/13/2023] [Accepted: 01/01/2024] [Indexed: 01/23/2024]
Abstract
Thiopurine is metabolized to 6-thio-(deoxy) guanosine triphosphate (6-thio-(d) GTP), which is then incorporated into DNA or RNA and causes cytotoxicity. Nudix hydrolase 15 (NUDT15) reduces the cytotoxic effects of thiopurine by converting 6-thio-(d) GTP to 6-thio-(d) guanosine monophosphate (6-thio-(d) GMP). NUDT15 polymorphisms like the Arg139Cys variant are strongly linked to thiopurine-induced severe leukocytopenia and alopecia. Therefore, measurement of NUDT15 enzymatic activity in individual patients can help predict thiopurine tolerability and adjust the dosage. We aimed to develop a quantitative assay for NUDT15 enzymatic activity in human blood samples. Blood samples were collected from donors whose NUDT15 genetic status was determined. Liquid chromatography-tandem mass spectrometry (LC-MS/MS) was used to assess the 6-thio-GTP metabolic activity in cell extracts. Because 6-thio-guanosine diphosphate (6-thio-GDP) and 6-thio-GMP were generated upon incubation of 6-thio-GTP with human blood cell extracts, the method detecting 6-thio-GTP, 6-thio-GDP, and 6-thio-GMP was validated. All three metabolites were linearly detected, and the lower limit of quantification (LLOQ) of 6-thio-GTP, 6-thio-GDP, and 6-thio-GMP were 5 μM, 1 μM, and 2 μM, respectively. Matrix effects of human blood cell extracts to detect 6-thio-GTP, 6-thio-GDP, and 6-thio-GMP were 99.0 %, 100.5 %, and 101.4 %, respectively, relative to the signals in the absence of blood cell extracts. The accuracy and precision of the method and the stability of the samples were also assessed. Using this established method, the genotype-dependent differences in NUDT15 activities were successfully determined using cell extracts derived from human blood cells with NUDT15 wild-type (WT) or Arg139Cys variant and 6-thio-GTP (100 μM) as a substrate (18.1, 14.9, and 6.43 μM/h/106 cells for WT, Arg139Cys heterozygous, and homozygous variant, respectively). We developed a method for quantifying intracellular NUDT15 activity in peripheral blood mononuclear cells (PBMCs), which we defined as the conversion of 6-thio-GTP to 6-thio-GMP. Although PBMCs preparation takes some time, its reproducibility in experiments makes it a promising candidate for clinical application. This method can tell the difference between WT and Arg139Cys homozygous blood samples. Even in patients with WT NUDT15, WT samples showed variations in NUDT15 activity, which may correlate with variations in thiopurine dosage.
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Affiliation(s)
- Hitomi Okamoto
- Laboratory of Biochemistry, Graduate School of Pharmaceutical Sciences, Japan; Department of Clinical Pharmacy, Graduate School of Pharmaceutical Sciences, Kitasato University, Tokyo, Japan
| | - Yoichi Tanaka
- Department of Clinical Pharmacy, Graduate School of Pharmaceutical Sciences, Kitasato University, Tokyo, Japan; Division of Medicinal Safety Science, National Institute of Health Sciences, Kanagawa, Japan.
| | - Yoshio Shibagaki
- Laboratory of Biochemistry, Graduate School of Pharmaceutical Sciences, Japan
| | - Satoshi Kuronuma
- Biomedical Laboratory, Department of Research, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Yusuke Miyatani
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan; Department of Gastroenterology and Hepatology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Satoko Umeda
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan; Department of Gastroenterology and Hepatology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Emi Mishiro-Sato
- Laboratory of Biochemistry, Graduate School of Pharmaceutical Sciences, Japan
| | - Osamu Takeuchi
- Biomedical Laboratory, Department of Research, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Seisuke Hattori
- Laboratory of Biochemistry, Graduate School of Pharmaceutical Sciences, Japan
| | - Taku Kobayashi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan; Department of Gastroenterology and Hepatology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Mitsuru Okuwaki
- Laboratory of Biochemistry, Graduate School of Pharmaceutical Sciences, Japan.
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Sands BE, Schreiber S, Blumenstein I, Chiorean MV, Ungaro RC, Rubin DT. Clinician's Guide to Using Ozanimod for the Treatment of Ulcerative Colitis. J Crohns Colitis 2023; 17:2012-2025. [PMID: 37436357 PMCID: PMC10798866 DOI: 10.1093/ecco-jcc/jjad112] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Indexed: 07/13/2023]
Abstract
The emergence of advanced therapies [eg, biologics, Janus kinase inhibitors] over the past few decades has revolutionised the treatment of ulcerative colitis. However, the limitations of these therapies leave an unmet need for safer and more effective or convenient treatment options. There is growing interest in the development of novel oral small molecule therapies for the treatment of ulcerative colitis. Ozanimod is an oral small molecule therapy that is approved in the USA, the European Union, and other countries as the first sphingosine 1-phosphate receptor modulator for the treatment of moderately to severely active ulcerative colitis in adults. This review provides guidance for ozanimod use for the treatment of ulcerative colitis, based on the prescribing information, clinical trial and real-world data, and the authors' clinical experiences. This guidance outlines patient characteristics to consider when deciding if ozanimod treatment is suitable and describes how to educate patients on risks and best practices. It also details the nature and frequency of monitoring during treatment, which should be adapted to the individual patient based on pre-existing risk factors and events that possibly occur during treatment. This review also provides insights into the patient characteristics and clinical scenarios best suited for ozanimod treatment, based on its efficacy, safety profile, and risks compared with other therapies.
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Affiliation(s)
- Bruce E Sands
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Stefan Schreiber
- Department of Internal Medicine I, University Hospital Schleswig-Holstein, Kiel University, Kiel, Germany
| | - Irina Blumenstein
- Medical Clinic 1, Department of Gastroenterology, Hepatology and Clinical Nutrition, Goethe University Hospital, Frankfurt, Germany
| | - Michael V Chiorean
- Department of Gastroenterology, Swedish Medical Center, Seattle, WA, USA
| | - Ryan C Ungaro
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David T Rubin
- Section of Gastroenterology, Hepatology & Nutrition, University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
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Nguyen ALH, Sparrow MP. Evolving Role of Thiopurines in Inflammatory Bowel Disease in the Era of Biologics and New Small Molecules. Dig Dis Sci 2021; 66:3250-3262. [PMID: 33073334 DOI: 10.1007/s10620-020-06662-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 10/06/2020] [Indexed: 12/09/2022]
Abstract
In recent years, with the increasing availability of biologic therapies and due to safety concerns, the role of thiopurines in the management of inflammatory bowel disease has been questioned. While acknowledging that the benefit/risk ratio of biologic therapies is very high, they are expensive and are not required by a majority of patients. Therefore, thiopurines do retain an important role as steroid-sparing and maintenance agents when used as monotherapy, and in combination therapy with biologics due to their clinical and pharmacokinetic optimization of anti-tumor necrosis factor agents in particular. Safety concerns with thiopurines are real but also relatively rare, and with careful pre-treatment screening and ongoing monitoring thiopurine benefits outweigh risks in the majority of appropriately selected patients. Measurement of newer pharmacogenomic markers such as nudix hydrolase 15 (NUDT15), when combined with knowledge of existing known mutations (e.g., thiopurine S-methyltransferase-TPMT), will hopefully minimize the risk of potentially life-threatening leukopenia by allowing for pre-treatment dosing stratification. Further optimization of thiopurine dosing via measurement of thiopurine metabolites should be performed routinely and is superior to weight-based dosing. The association of thiopurines with malignancies including lymphoproliferative disorders needs to be recognized in all patients and individualized in each patient. The decrease in lymphoma risk after thiopurine cessation provides an incentive for thiopurine de-escalation in appropriate patients after a period of prolonged deep remission. This review will summarize the current role of thiopurines in inflammatory bowel disease management and provide recommendations for commencing and monitoring therapy, and when to consider de-escalation.
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Affiliation(s)
- Anke L H Nguyen
- Department of Gastroenterology, Alfred Health, 55 Commercial Road, Melbourne, 3004, VIC, Australia.,Monash University, Melbourne, Australia
| | - Miles P Sparrow
- Department of Gastroenterology, Alfred Health, 55 Commercial Road, Melbourne, 3004, VIC, Australia. .,Monash University, Melbourne, Australia.
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Genova E, Lucafò M, Pelin M, Di Paolo V, Quintieri L, Decorti G, Stocco G. Insights into the cellular pharmacokinetics and pharmacodynamics of thiopurine antimetabolites in a model of human intestinal cells. Chem Biol Interact 2021; 347:109624. [PMID: 34416244 DOI: 10.1016/j.cbi.2021.109624] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 08/04/2021] [Accepted: 08/16/2021] [Indexed: 02/07/2023]
Abstract
Thiopurines, immunomodulating drugs used in the management of different chronic autoimmune conditions and as anti-leukemic agents, may exert in some cases gastrointestinal toxicity. Moreover, since these agents are administered orally, they are absorbed across the gastrointestinal tract epithelium. On these premises, cellular and molecular events occurring in intestinal cells may be important to understand thiopurine effects. However, quantitative information on the biotransformation of thiopurines in intestinal tissues is still limited. To shed light on biotransformation processes specific of the intestinal tissue, in this study thiopurine metabolites concentrations were analyzed by an in vitro model of human healthy colon, the HCEC cell line, upon exposure to cytotoxic concentrations of azathioprine or mercaptopurine; the investigation was carried out using an innovative mass spectrometry method, that allowed the simultaneous quantification of 11 mono-, di-, and triphosphate thionucleotides. Among the 11 metabolites evaluated, TIMP, TGMP, TGDP, TGTP, MeTIMP, MeTIDP and MeTITP were detectable in HCEC cells treated with azathioprine or mercaptopurine, considering two different incubation times before the addition of the drugs (4 and 48 h). Different associations between metabolites concentrations and cytotoxicity were detected. In particular, the cytotoxicity was dependent on the TGMP, TGDP, TGTP and MeTITP concentrations after the 4 h incubation before the addition of thiopurines. This may be an indication that, to study the association between thiopurine metabolite concentrations and the cytotoxicity activity in vitro, short growth times before treatment should be used. Moreover, for the first time our findings highlight the strong correlation between cytotoxicity and thiopurine pharmacokinetics in HCEC intestinal cells in vitro suggesting that these cells could be a suitable in vitro model for studying thiopurine intestinal cytotoxicity.
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Affiliation(s)
- Elena Genova
- Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | - Marianna Lucafò
- Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | - Marco Pelin
- Department of Life Sciences, University of Trieste, Trieste, Italy
| | - Veronica Di Paolo
- Laboratory of Drug Metabolism, Department of Pharmaceutical and Pharmacological Sciences, University of Padova, Padova, Italy
| | - Luigi Quintieri
- Laboratory of Drug Metabolism, Department of Pharmaceutical and Pharmacological Sciences, University of Padova, Padova, Italy
| | - Giuliana Decorti
- Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy; Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy.
| | - Gabriele Stocco
- Department of Life Sciences, University of Trieste, Trieste, Italy
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Naymagon L, Tremblay D, Zubizarreta N, Moshier E, Naymagon S, Mascarenhas J, Schiano T. The Natural History, Treatments, and Outcomes of Portal Vein Thrombosis in Patients With Inflammatory Bowel Disease. Inflamm Bowel Dis 2021; 27:215-223. [PMID: 32185400 PMCID: PMC8427727 DOI: 10.1093/ibd/izaa053] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Portal vein thrombosis (PVT) is a poorly described complication of inflammatory bowel disease (IBD). We sought to better characterize presentations, compare treatments, and assess outcomes in IBD-related PVT. METHODS We conducted a retrospective investigation of IBD-related PVT at our institution. Multivariable Cox proportional hazards modeling was used to estimate adjusted hazard ratios across treatments. RESULTS Sixty-three patients with IBD-related PVT (26 with Crohn disease, 37 with ulcerative colitis) were followed for a median 21 months (interquartile ratio [IQR] = 9-52). Major risk factors included intra-abdominal surgery (60%), IBD flare (33%), and intra-abdominal infection (13%). Primary hematologic thrombophilias were rare and did not impact management. Presentations were generally nonspecific, and diagnosis was incidental. Ninety-two percent of patients (58/63) received anticoagulation (AC), including 23 who received direct oral anticoagulants (DOACs), 22 who received warfarin, and 13 who received enoxaparin. All anticoagulated patients started AC within 3 days of diagnosis. Complete radiographic resolution (CRR) of PVT occurred in 71% of patients. We found that DOACs were associated with higher CRR rates (22/23; 96%) relative to warfarin (12/22; 55%): the hazard ratio of DOACs to warfarin was 4.04 (1.83-8.93; P = 0.0006)). Patients receiving DOACs required shorter courses of AC (median 3.9 months; IQR = 2.7-6.1) than those receiving warfarin (median 8.5 months; IQR = 3.9-NA; P = 0.0190). Incidence of gut ischemia (n = 3), symptomatic portal hypertension (n = 3), major bleeding (n = 4), and death (n = 2) were rare, and no patients receiving DOACs experienced these adverse outcomes. CONCLUSIONS We show that early and aggressive use of AC can lead to excellent outcomes in IBD-associated PVT and that DOACs are associated with particularly favorable outcomes in this setting.
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Affiliation(s)
- Leonard Naymagon
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Douglas Tremblay
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nicole Zubizarreta
- Department of Population Health Science and Policy/Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Erin Moshier
- Department of Population Health Science and Policy/Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Steven Naymagon
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Thomas Schiano
- Division of Liver Diseases, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Discontinuation of Immunosuppressive Medications in Children With Inflammatory Bowel Disease on Combination Therapy. J Pediatr Gastroenterol Nutr 2020; 71:740-743. [PMID: 32740529 DOI: 10.1097/mpg.0000000000002857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
We determined the frequency and factors associated with the first clinical relapse after immunomodulator (IM) withdrawal in a cohort of children with inflammatory bowel disease on combination therapy. A total of 105 patients (89 with Crohn disease [CD]) in clinical remission were included (91 [86.7%] were on infliximab, 53 [50.5%] with methotrexate, and 52 on azathioprine). The median duration of combination therapy was 2.1 years (interquartile range [IQR] 1.3-2.8). Only 11 (10.5%) patients experienced a clinical relapse over a median duration of follow-up of 12.0 months (IQR 5.0-19.0) after IM discontinuation. The median baseline pediatric CD activity index in those with CD who relapsed after IM discontinuation was 47.5 (IQR: 35.0-55.0) versus those who did not relapse (median 35.0, IQR: 20.0-52.5; P = 0.04). In the patients who did not relapse, the median IFX trough level at IM discontinuation was 6.2 and 3.8 μg/mL in those who relapsed.
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Hisamatsu T, Kim HJ, Motoya S, Suzuki Y, Ohnishi Y, Fujii N, Matsushima N, Zheng R, Marano CW. Efficacy and safety of ustekinumab in East Asian patients with moderately to severely active ulcerative colitis: a subpopulation analysis of global phase 3 induction and maintenance studies (UNIFI). Intest Res 2020; 19:386-397. [PMID: 33249802 PMCID: PMC8566834 DOI: 10.5217/ir.2020.00080] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 10/03/2020] [Indexed: 11/16/2022] Open
Abstract
Background/Aims We aimed to evaluate the efficacy and safety of ustekinumab (UST) in the East-Asian population with moderate to severely active ulcerative colitis (UC). Methods This sub-analysis was conducted on data from East-Asian patients included in the UNIFI program (NCT02407236). UNIFI consisted of two double-blind, placebo-controlled trials: an 8-week induction study and a 44-week randomized withdrawal maintenance study. Results Of 133 East-Asian patients (Japanese: 107, Korean: 26) who underwent randomization, 131 completed induction study and 111 entered maintenance study. In the maintenance study, 78 patients were randomized. Patients who received UST 130 mg and UST 6 mg/kg showed numerically higher clinical remission at week 8 in the induction study (5/44 [11.4%] and 5/45 [11.1%], respectively) compared with those who received placebo (0/44, 0%). The proportion of patients achieved clinical remission at week 44 was numerically higher in the UST 90 mg q12w group (10/21, 47.6%), but similar in the UST 90 mg q8w group (5/26, 19.2%) compared to placebo (7/31, 22.6%). Serious adverse events were reported in 1 patient in UST 130 mg group, but no patient in UST 6 mg/kg group through week 8 in the induction study, and 1 patient in UST 90 mg q12w group and 5 patients in the UST 90 mg q8w group in the maintenance study. No deaths were reported in East-Asian patients throughout the study. Conclusions UST induction and maintenance treatments were effective in East-Asian patients with moderate to severe UC; the efficacy and safety profiles were consistent with the overall population.
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Affiliation(s)
- Tadakazu Hisamatsu
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Hyo Jong Kim
- Center for Crohn's and Colitis, Department of Gastroenterology, Kyung Hee University College of Medicine, Seoul, Korea
| | - Satoshi Motoya
- IBD Center, Hokkaido Prefectural Welfare Federation of Agricultural Cooperative, Sapporo-Kosei General, Hokkaido, Japan
| | - Yasuo Suzuki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Sakura Medical Center, Sakura, Japan
| | - Yoshifumi Ohnishi
- Division of Gastroenterology, Shizuoka Medical Center, Shizuoka, Japan
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Lin R, Lin W, Wang C, Dong J, Zheng W, Zeng D, Liu Y, Lin C, Jiao Z, Huang P. Population pharmacokinetics of azathioprine active metabolite in patients with inflammatory bowel disease and dosage regimens optimisation. Basic Clin Pharmacol Toxicol 2020; 128:482-492. [PMID: 33150655 DOI: 10.1111/bcpt.13530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 10/12/2020] [Accepted: 11/02/2020] [Indexed: 12/25/2022]
Abstract
Azathioprine is a first-line drug used to maintain the remission of inflammatory bowel disease (IBD). As a prodrug, azathioprine is metabolised to produce active 6-thioguanine nucleotides (6-TGN). There are large individual variations in the pharmacokinetics/pharmacodynamics of 6-TGN in patients with IBD. Here, we aimed to develop a model to quantitatively investigate factors that affect 6-TGN pharmacokinetics to formulate a dosage guideline for azathioprine. Data were collected prospectively from 100 adult patients with IBD who were receiving azathioprine. Patients were genotyped for two single-nucleotide polymorphisms (TPMT*3C c.719A > G and NUDT15 c.415C > T). Using high-performance liquid chromatography, we measured 156 steady-state trough concentrations of 6-TGN within the range 0.09 to 1.16 mg/L (ie 133-1733 pmol per 8 × 108 RBC). The covariates analysed included sex, age, body-weight, laboratory tests and concomitant medications. A population pharmacokinetic model was established using "non-linear mixed-effects modelling" software and the "first-order conditional estimation method with interaction." Body-weight, TPMT*3C polymorphisms and co-therapy with mesalazine were found to be important factors influencing the clearance of 6-TGN. A dosage guideline for azathioprine was developed based on the PPK model that enables individualised azathioprine dosing in adult patients with different body-weights, TPMT*3C genotypes and co-administration with mesalazine.
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Affiliation(s)
- Rongfang Lin
- Department of Pharmacy, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Weiwei Lin
- Department of Pharmacy, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Changlian Wang
- Department of Pharmacy, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Jiashan Dong
- Department of Pharmacy, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Weiwei Zheng
- Department of Gastroenterology, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Dayong Zeng
- Department of Pharmacy, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Yiwei Liu
- Department of Pharmacy, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Cuihong Lin
- Department of Pharmacy, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Zheng Jiao
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Pinfang Huang
- Department of Pharmacy, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
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11
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Hypersensitivity to IV Ustekinumab but Tolerance to Subcutaneous Ustekinumab in a Patient With Crohn's Disease. ACG Case Rep J 2020; 7:e00449. [PMID: 32904020 PMCID: PMC7449253 DOI: 10.14309/crj.0000000000000449] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/08/2020] [Indexed: 12/13/2022] Open
Abstract
Ustekinumab is a monoclonal antibody against the p40 subunit of interleukin (IL)-12 and IL-23 and is US Food and Drug Administration (FDA)-approved for plaque psoriasis, moderately to severely active Crohn's disease, and ulcerative colitis. We describe a case of an immediate hypersensitivity reaction to ustekinumab infusion with no reaction to subsequent ustekinumab subcutaneous maintenance therapy. We identify ethylenediaminetetraacetic acid as a unique excipient found in the intravenous formulation compared with the prefilled syringe used for subcutaneous injections, which is likely to account for this observation. No similar cases have been reported in the literature.
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12
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Hamdy SM, Abdel-Naseer M, Shehata HS, Shalaby NM, Hassan A, Elmazny A, Shaker E, Nada MAF, Ahmed SM, Hegazy MI, Mourad HS, Abdelalim A, Magdy R, Othman AS, Mekkawy DA, Kishk NA. Management Strategies of Patients with Neuromyelitis Optica Spectrum Disorder During the COVID-19 Pandemic Era. Ther Clin Risk Manag 2020; 16:759-767. [PMID: 32884277 PMCID: PMC7443007 DOI: 10.2147/tcrm.s261753] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 08/03/2020] [Indexed: 12/29/2022] Open
Abstract
The ongoing coronavirus (COVID-19) pandemic is a global health emergency of international concern and has affected management plans of many autoimmune disorders. Immunosuppressive and immunomodulatory therapies are pivotal in the management of neuromyelitis optica spectrum disorder (NMOSD), potentially placing patients at an increased risk of contracting infections such as COVID-19. The optimal management strategy of NMOSD during the COVID-19 era remains unclear. Here, however, we examined the evidence of NMOSD disease-modifying therapies (DMTs) use during the present period and highlighted different scenarios including treatment of relapses as well as initiation and maintenance of DMTs in order to optimize care of NMOSD patients in the COVID-19 era.
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Affiliation(s)
- Sherif M Hamdy
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Maged Abdel-Naseer
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hatem S Shehata
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Nevin M Shalaby
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Amr Hassan
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Alaa Elmazny
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ehab Shaker
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mona A F Nada
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Sandra M Ahmed
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed I Hegazy
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Husam S Mourad
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Abdelalim
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Rehab Magdy
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Alshimaa S Othman
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Doaa A Mekkawy
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Nirmeen A Kishk
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
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13
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El-Matary W. Thiopurine Methyltransferase Activity and Thiopurine Metabolites in Inflammatory Bowel Disease. CROHN'S & COLITIS 360 2020; 2:otaa062. [PMID: 36798512 PMCID: PMC9927816 DOI: 10.1093/crocol/otaa062] [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: 06/28/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Wael El-Matary
- Address correspondence to: Wael El-Matary, MBBCh, MD, MSc, FRCPCH, FRCPC, University of Manitoba, AE 408 Children’s Hospital, Health Sciences Centre, 840 Sherbrook St., Winnipeg, MB R3A 1S1 ()
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14
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15
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Plevinsky JM, Wojtowicz AA, Miller SA, Greenley RN. Longitudinal Barriers to Thiopurine Adherence in Adolescents With Inflammatory Bowel Diseases. J Pediatr Psychol 2020; 44:52-60. [PMID: 30137372 DOI: 10.1093/jpepsy/jsy062] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 07/20/2018] [Indexed: 01/29/2023] Open
Abstract
Objectives Cross-sectionally, more adherence barriers are associated with lower medication adherence. However, little is known about longitudinal associations between adherence barriers and adherence. Among adolescents with inflammatory bowel diseases (IBD), this study examined both (1) how time-varying self-reported adherence barriers affect daily thiopurine adherence and (2) how adherence barriers at baseline affect daily thiopurine adherence over a six-month period. Methods Eighty-one adolescents 11-18 years old prescribed a once-daily oral IBD maintenance medication participated in a six-month observational study. Adherence barriers were self-reported monthly via the Medication Adherence Measure (MAM): Medication Subscale. Daily adherence estimates were collected via Medication Event Monitoring System (MEMS) Track Caps. Results Generalized linear mixed modeling indicated that time alone did not significantly predict whether one was more likely to be adherent (p = .602). However, increasing adherence barriers lowered the likelihood that a participant would be adherent on a given day, and the interaction between time and barriers predicted likelihood of adherence on a given day (p < .01). Specifically, when participants reported no adherence barriers at baseline, adherence did not significantly change over time (p = .369). However, when barriers were endorsed, adherence decreased over time (p < .01). Conclusions Fewer adherence barriers over time predicted greater likelihood of adherence on a given day, which is consistent with previous cross-sectional research. Routine assessment of barriers to adherence over the course of adolescence is critical in addressing suboptimal adherence behavior in youth with IBD.
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16
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El-Matary W, Leung S, Tennakoon A, Benchimol EI, Bernstein CN, Targownik LE. Trends of Utilization of Tumor Necrosis Factor Antagonists in Children With Inflammatory Bowel Disease: A Canadian Population-Based Study. Inflamm Bowel Dis 2020; 26:134-138. [PMID: 31323083 DOI: 10.1093/ibd/izz157] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Population-based studies examining the prevalence of anti-tumor necrosis factor (anti-TNF) antagonist utilization in children and young adults with inflammatory bowel disease (IBD) are lacking. We aimed to describe the trend of anti-TNF utilization in pediatric IBD over time. METHODS Survival analyses were performed for all patients diagnosed with IBD before age 18 years in the province of Manitoba to determine the time from diagnosis to first anti-TNF prescription in different time eras (2005-2008, 2008-2012, 2012-2016). RESULTS There were 291 persons diagnosed with IBD (157 with Crohn's disease [CD] and 134 with ulcerative colitis [UC]) over the study period. The likelihood of being initiated on an anti-TNF by 1, 2, and 5 years postdiagnosis was 18.4%, 30.5%, and 42.6%, respectively. The proportion of persons aged <18 years utilizing anti-TNFs rose over time; in 2010, 13.0% of CD and 4.9% of UC; by 2016, 60.0% of CD and 25.5% of UC. For those diagnosed after 2012, 42.5% of CD and 28.4% of UC patients had been prescribed an anti-TNF antagonist within 12 months of IBD diagnosis. Initiating an anti-TNF without prior exposure to an immunosuppressive agent increased over time (before 2008: 0%; 2008-2012: 18.2%; 2012-2016: 42.8%; P < 0.001). There was a significant reduction in median cumulative dose of corticosteroids (CS) in the year before anti-TNF initiation (2005-2008: 4360 mg; 2008-2012: 2010 mg; 2012-2016: 1395 mg prednisone equivalents; P < 0.001). CONCLUSIONS Over a period of 11 years, anti-TNFs are being used earlier in the course of pediatric IBD, with a parallel reduction in the cumulative CS dose.
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Affiliation(s)
- Wael El-Matary
- Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada.,University of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Stella Leung
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Aruni Tennakoon
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Eric I Benchimol
- Department of Pediatrics and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada.,Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Charles N Bernstein
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,University of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Laura E Targownik
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,University of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
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17
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El-Matary W, Bernstein CN. Cancer Risk in Pediatric-Onset Inflammatory Bowel Disease. Front Pediatr 2020; 8:400. [PMID: 32903330 PMCID: PMC7396532 DOI: 10.3389/fped.2020.00400] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/10/2020] [Indexed: 12/20/2022] Open
Abstract
Inflammatory bowel disease (IBD) is a chronic, immune-mediated, non-curable disease. The incidence of IBD appears to have risen over the last few decades especially in the pediatric age group. IBD usually presents with gastrointestinal symptoms, including abdominal pain, diarrhea, and bleeding per rectum but can also be associated with systemic symptoms such as weight loss, fatigue, joint and skin problems, and psychological comorbidities. One major complication is gastrointestinal and extra-intestinal malignancy. This review discusses literature that focuses on cancer risk of pediatric-onset IBD.
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Affiliation(s)
- Wael El-Matary
- Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada.,IBD Clinical and Research Center, University of Manitoba, Winnipeg, MB, Canada
| | - Charles N Bernstein
- IBD Clinical and Research Center, University of Manitoba, Winnipeg, MB, Canada.,Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
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18
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Calafat M, Mañosa M, Cañete F, Ricart E, Iglesias E, Calvo M, Rodríguez-Moranta F, Taxonera C, Nos P, Mesonero F, Martín-Arranz MD, Mínguez M, Gisbert JP, García-López S, de Francisco R, Gomollón F, Calvet X, Garcia-Planella E, Rivero M, Martínez-Cadilla J, Argüelles F, Arias L, Cimavilla M, Zabana Y, Domènech E. Increased risk of thiopurine-related adverse events in elderly patients with IBD. Aliment Pharmacol Ther 2019; 50:780-788. [PMID: 31429097 DOI: 10.1111/apt.15458] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 05/27/2019] [Accepted: 07/20/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Thiopurines are the most widely used immunosuppressants in IBD although drug-related adverse events (AE) occur in 20%-30% of cases. AIM To evaluate the safety of thiopurines in elderly IBD patients METHODS: Cohort study including all adult patients in the ENEIDA registry who received thiopurines. Patients were grouped in terms of age at the beginning of thiopurine treatment, specifically in those who started thiopurines over 60 years or between 18 and 50 years of age. Thiopurine-related AEs registered in the ENEIDA database were compared. RESULTS Out of 48 752 patients, 1888 started thiopurines when over 60 years of age and 15 477 under 50 years of age. Median treatment duration was significantly shorter for those who started thiopurines >60 years (13 [IQR 2-55] vs 32 [IQR 5-82] months; P < .001). Patients starting >60 years had higher rates of all types of myelotoxicity, digestive intolerance and hepatotoxicity. Thiopurines were discontinued due to AEs (excluding malignancies and infections) in more patients starting >60 years (67.2% vs 63.1%; P < .001). Elderly age and female sex were independent risk factors for most AEs. CONCLUSION In elderly IBD patients, thiopurines are associated with an increased risk of non-infectious, non-neoplastic, AEs.
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19
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Sands BE, Sandborn WJ, Panaccione R, O'Brien CD, Zhang H, Johanns J, Adedokun OJ, Li K, Peyrin-Biroulet L, Van Assche G, Danese S, Targan S, Abreu MT, Hisamatsu T, Szapary P, Marano C. Ustekinumab as Induction and Maintenance Therapy for Ulcerative Colitis. N Engl J Med 2019; 381:1201-1214. [PMID: 31553833 DOI: 10.1056/nejmoa1900750] [Citation(s) in RCA: 631] [Impact Index Per Article: 126.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND The efficacy of ustekinumab, an antagonist of the p40 subunit of interleukin-12 and interleukin-23, as induction and maintenance therapy in patients with ulcerative colitis is unknown. METHODS We evaluated ustekinumab as 8-week induction therapy and 44-week maintenance therapy in patients with moderate-to-severe ulcerative colitis. A total of 961 patients were randomly assigned to receive an intravenous induction dose of ustekinumab (either 130 mg [320 patients] or a weight-range-based dose that approximated 6 mg per kilogram of body weight [322]) or placebo (319). Patients who had a response to induction therapy 8 weeks after administration of intravenous ustekinumab were randomly assigned again to receive subcutaneous maintenance injections of 90 mg of ustekinumab (either every 12 weeks [172 patients] or every 8 weeks [176]) or placebo (175). The primary end point in the induction trial (week 8) and the maintenance trial (week 44) was clinical remission (defined as a total score of ≤2 on the Mayo scale [range, 0 to 12, with higher scores indicating more severe disease] and no subscore >1 [range, 0 to 3] on any of the four Mayo scale components). RESULTS The percentage of patients who had clinical remission at week 8 among patients who received intravenous ustekinumab at a dose of 130 mg (15.6%) or 6 mg per kilogram (15.5%) was significantly higher than that among patients who received placebo (5.3%) (P<0.001 for both comparisons). Among patients who had a response to induction therapy with ustekinumab and underwent a second randomization, the percentage of patients who had clinical remission at week 44 was significantly higher among patients assigned to 90 mg of subcutaneous ustekinumab every 12 weeks (38.4%) or every 8 weeks (43.8%) than among those assigned to placebo (24.0%) (P = 0.002 and P<0.001, respectively). The incidence of serious adverse events with ustekinumab was similar to that with placebo. Through 52 weeks of exposure, there were two deaths (one each from acute respiratory distress syndrome and hemorrhage from esophageal varices) and seven cases of cancer (one each of prostate, colon, renal papillary, and rectal cancer and three nonmelanoma skin cancers) among 825 patients who received ustekinumab and no deaths and one case of cancer (testicular cancer) among 319 patients who received placebo. CONCLUSIONS Ustekinumab was more effective than placebo for inducing and maintaining remission in patients with moderate-to-severe ulcerative colitis. (Funded by Janssen Research and Development; UNIFI ClinicalTrials.gov number, NCT02407236.).
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Affiliation(s)
- Bruce E Sands
- From the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York (B.E.S.); the Division of Gastroenterology, University of California, San Diego, La Jolla (W.J.S.), and the F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; the Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada (R.P.); Janssen Research and Development, Spring House, PA (C.D.O., H.Z., J.J., O.J.A., K.L., P.S., C.M.); the Gastroenterology Department and INSERM 1256, Nutrition, Genetics, and Environmental Risk Exposure, Nancy University Hospital, Université de Lorraine, Nancy, France (L.P.-B.); the Division of Gastroenterology and Hepatology, University Hospitals Leuven and Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium (G.V.A.); the IBD Center, Department of Gastroenterology, Humanitas Research Hospital and Humanitas University, Milan (S.D.); the Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami (M.T.A.); and the Division of Gastroenterology, Third Department of Internal Medicine, Kyorin University School of Medicine, Tokyo (T.H.)
| | - William J Sandborn
- From the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York (B.E.S.); the Division of Gastroenterology, University of California, San Diego, La Jolla (W.J.S.), and the F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; the Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada (R.P.); Janssen Research and Development, Spring House, PA (C.D.O., H.Z., J.J., O.J.A., K.L., P.S., C.M.); the Gastroenterology Department and INSERM 1256, Nutrition, Genetics, and Environmental Risk Exposure, Nancy University Hospital, Université de Lorraine, Nancy, France (L.P.-B.); the Division of Gastroenterology and Hepatology, University Hospitals Leuven and Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium (G.V.A.); the IBD Center, Department of Gastroenterology, Humanitas Research Hospital and Humanitas University, Milan (S.D.); the Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami (M.T.A.); and the Division of Gastroenterology, Third Department of Internal Medicine, Kyorin University School of Medicine, Tokyo (T.H.)
| | - Remo Panaccione
- From the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York (B.E.S.); the Division of Gastroenterology, University of California, San Diego, La Jolla (W.J.S.), and the F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; the Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada (R.P.); Janssen Research and Development, Spring House, PA (C.D.O., H.Z., J.J., O.J.A., K.L., P.S., C.M.); the Gastroenterology Department and INSERM 1256, Nutrition, Genetics, and Environmental Risk Exposure, Nancy University Hospital, Université de Lorraine, Nancy, France (L.P.-B.); the Division of Gastroenterology and Hepatology, University Hospitals Leuven and Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium (G.V.A.); the IBD Center, Department of Gastroenterology, Humanitas Research Hospital and Humanitas University, Milan (S.D.); the Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami (M.T.A.); and the Division of Gastroenterology, Third Department of Internal Medicine, Kyorin University School of Medicine, Tokyo (T.H.)
| | - Christopher D O'Brien
- From the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York (B.E.S.); the Division of Gastroenterology, University of California, San Diego, La Jolla (W.J.S.), and the F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; the Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada (R.P.); Janssen Research and Development, Spring House, PA (C.D.O., H.Z., J.J., O.J.A., K.L., P.S., C.M.); the Gastroenterology Department and INSERM 1256, Nutrition, Genetics, and Environmental Risk Exposure, Nancy University Hospital, Université de Lorraine, Nancy, France (L.P.-B.); the Division of Gastroenterology and Hepatology, University Hospitals Leuven and Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium (G.V.A.); the IBD Center, Department of Gastroenterology, Humanitas Research Hospital and Humanitas University, Milan (S.D.); the Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami (M.T.A.); and the Division of Gastroenterology, Third Department of Internal Medicine, Kyorin University School of Medicine, Tokyo (T.H.)
| | - Hongyan Zhang
- From the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York (B.E.S.); the Division of Gastroenterology, University of California, San Diego, La Jolla (W.J.S.), and the F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; the Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada (R.P.); Janssen Research and Development, Spring House, PA (C.D.O., H.Z., J.J., O.J.A., K.L., P.S., C.M.); the Gastroenterology Department and INSERM 1256, Nutrition, Genetics, and Environmental Risk Exposure, Nancy University Hospital, Université de Lorraine, Nancy, France (L.P.-B.); the Division of Gastroenterology and Hepatology, University Hospitals Leuven and Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium (G.V.A.); the IBD Center, Department of Gastroenterology, Humanitas Research Hospital and Humanitas University, Milan (S.D.); the Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami (M.T.A.); and the Division of Gastroenterology, Third Department of Internal Medicine, Kyorin University School of Medicine, Tokyo (T.H.)
| | - Jewel Johanns
- From the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York (B.E.S.); the Division of Gastroenterology, University of California, San Diego, La Jolla (W.J.S.), and the F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; the Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada (R.P.); Janssen Research and Development, Spring House, PA (C.D.O., H.Z., J.J., O.J.A., K.L., P.S., C.M.); the Gastroenterology Department and INSERM 1256, Nutrition, Genetics, and Environmental Risk Exposure, Nancy University Hospital, Université de Lorraine, Nancy, France (L.P.-B.); the Division of Gastroenterology and Hepatology, University Hospitals Leuven and Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium (G.V.A.); the IBD Center, Department of Gastroenterology, Humanitas Research Hospital and Humanitas University, Milan (S.D.); the Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami (M.T.A.); and the Division of Gastroenterology, Third Department of Internal Medicine, Kyorin University School of Medicine, Tokyo (T.H.)
| | - Omoniyi J Adedokun
- From the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York (B.E.S.); the Division of Gastroenterology, University of California, San Diego, La Jolla (W.J.S.), and the F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; the Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada (R.P.); Janssen Research and Development, Spring House, PA (C.D.O., H.Z., J.J., O.J.A., K.L., P.S., C.M.); the Gastroenterology Department and INSERM 1256, Nutrition, Genetics, and Environmental Risk Exposure, Nancy University Hospital, Université de Lorraine, Nancy, France (L.P.-B.); the Division of Gastroenterology and Hepatology, University Hospitals Leuven and Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium (G.V.A.); the IBD Center, Department of Gastroenterology, Humanitas Research Hospital and Humanitas University, Milan (S.D.); the Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami (M.T.A.); and the Division of Gastroenterology, Third Department of Internal Medicine, Kyorin University School of Medicine, Tokyo (T.H.)
| | - Katherine Li
- From the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York (B.E.S.); the Division of Gastroenterology, University of California, San Diego, La Jolla (W.J.S.), and the F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; the Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada (R.P.); Janssen Research and Development, Spring House, PA (C.D.O., H.Z., J.J., O.J.A., K.L., P.S., C.M.); the Gastroenterology Department and INSERM 1256, Nutrition, Genetics, and Environmental Risk Exposure, Nancy University Hospital, Université de Lorraine, Nancy, France (L.P.-B.); the Division of Gastroenterology and Hepatology, University Hospitals Leuven and Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium (G.V.A.); the IBD Center, Department of Gastroenterology, Humanitas Research Hospital and Humanitas University, Milan (S.D.); the Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami (M.T.A.); and the Division of Gastroenterology, Third Department of Internal Medicine, Kyorin University School of Medicine, Tokyo (T.H.)
| | - Laurent Peyrin-Biroulet
- From the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York (B.E.S.); the Division of Gastroenterology, University of California, San Diego, La Jolla (W.J.S.), and the F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; the Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada (R.P.); Janssen Research and Development, Spring House, PA (C.D.O., H.Z., J.J., O.J.A., K.L., P.S., C.M.); the Gastroenterology Department and INSERM 1256, Nutrition, Genetics, and Environmental Risk Exposure, Nancy University Hospital, Université de Lorraine, Nancy, France (L.P.-B.); the Division of Gastroenterology and Hepatology, University Hospitals Leuven and Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium (G.V.A.); the IBD Center, Department of Gastroenterology, Humanitas Research Hospital and Humanitas University, Milan (S.D.); the Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami (M.T.A.); and the Division of Gastroenterology, Third Department of Internal Medicine, Kyorin University School of Medicine, Tokyo (T.H.)
| | - Gert Van Assche
- From the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York (B.E.S.); the Division of Gastroenterology, University of California, San Diego, La Jolla (W.J.S.), and the F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; the Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada (R.P.); Janssen Research and Development, Spring House, PA (C.D.O., H.Z., J.J., O.J.A., K.L., P.S., C.M.); the Gastroenterology Department and INSERM 1256, Nutrition, Genetics, and Environmental Risk Exposure, Nancy University Hospital, Université de Lorraine, Nancy, France (L.P.-B.); the Division of Gastroenterology and Hepatology, University Hospitals Leuven and Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium (G.V.A.); the IBD Center, Department of Gastroenterology, Humanitas Research Hospital and Humanitas University, Milan (S.D.); the Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami (M.T.A.); and the Division of Gastroenterology, Third Department of Internal Medicine, Kyorin University School of Medicine, Tokyo (T.H.)
| | - Silvio Danese
- From the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York (B.E.S.); the Division of Gastroenterology, University of California, San Diego, La Jolla (W.J.S.), and the F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; the Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada (R.P.); Janssen Research and Development, Spring House, PA (C.D.O., H.Z., J.J., O.J.A., K.L., P.S., C.M.); the Gastroenterology Department and INSERM 1256, Nutrition, Genetics, and Environmental Risk Exposure, Nancy University Hospital, Université de Lorraine, Nancy, France (L.P.-B.); the Division of Gastroenterology and Hepatology, University Hospitals Leuven and Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium (G.V.A.); the IBD Center, Department of Gastroenterology, Humanitas Research Hospital and Humanitas University, Milan (S.D.); the Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami (M.T.A.); and the Division of Gastroenterology, Third Department of Internal Medicine, Kyorin University School of Medicine, Tokyo (T.H.)
| | - Stephan Targan
- From the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York (B.E.S.); the Division of Gastroenterology, University of California, San Diego, La Jolla (W.J.S.), and the F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; the Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada (R.P.); Janssen Research and Development, Spring House, PA (C.D.O., H.Z., J.J., O.J.A., K.L., P.S., C.M.); the Gastroenterology Department and INSERM 1256, Nutrition, Genetics, and Environmental Risk Exposure, Nancy University Hospital, Université de Lorraine, Nancy, France (L.P.-B.); the Division of Gastroenterology and Hepatology, University Hospitals Leuven and Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium (G.V.A.); the IBD Center, Department of Gastroenterology, Humanitas Research Hospital and Humanitas University, Milan (S.D.); the Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami (M.T.A.); and the Division of Gastroenterology, Third Department of Internal Medicine, Kyorin University School of Medicine, Tokyo (T.H.)
| | - Maria T Abreu
- From the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York (B.E.S.); the Division of Gastroenterology, University of California, San Diego, La Jolla (W.J.S.), and the F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; the Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada (R.P.); Janssen Research and Development, Spring House, PA (C.D.O., H.Z., J.J., O.J.A., K.L., P.S., C.M.); the Gastroenterology Department and INSERM 1256, Nutrition, Genetics, and Environmental Risk Exposure, Nancy University Hospital, Université de Lorraine, Nancy, France (L.P.-B.); the Division of Gastroenterology and Hepatology, University Hospitals Leuven and Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium (G.V.A.); the IBD Center, Department of Gastroenterology, Humanitas Research Hospital and Humanitas University, Milan (S.D.); the Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami (M.T.A.); and the Division of Gastroenterology, Third Department of Internal Medicine, Kyorin University School of Medicine, Tokyo (T.H.)
| | - Tadakazu Hisamatsu
- From the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York (B.E.S.); the Division of Gastroenterology, University of California, San Diego, La Jolla (W.J.S.), and the F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; the Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada (R.P.); Janssen Research and Development, Spring House, PA (C.D.O., H.Z., J.J., O.J.A., K.L., P.S., C.M.); the Gastroenterology Department and INSERM 1256, Nutrition, Genetics, and Environmental Risk Exposure, Nancy University Hospital, Université de Lorraine, Nancy, France (L.P.-B.); the Division of Gastroenterology and Hepatology, University Hospitals Leuven and Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium (G.V.A.); the IBD Center, Department of Gastroenterology, Humanitas Research Hospital and Humanitas University, Milan (S.D.); the Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami (M.T.A.); and the Division of Gastroenterology, Third Department of Internal Medicine, Kyorin University School of Medicine, Tokyo (T.H.)
| | - Philippe Szapary
- From the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York (B.E.S.); the Division of Gastroenterology, University of California, San Diego, La Jolla (W.J.S.), and the F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; the Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada (R.P.); Janssen Research and Development, Spring House, PA (C.D.O., H.Z., J.J., O.J.A., K.L., P.S., C.M.); the Gastroenterology Department and INSERM 1256, Nutrition, Genetics, and Environmental Risk Exposure, Nancy University Hospital, Université de Lorraine, Nancy, France (L.P.-B.); the Division of Gastroenterology and Hepatology, University Hospitals Leuven and Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium (G.V.A.); the IBD Center, Department of Gastroenterology, Humanitas Research Hospital and Humanitas University, Milan (S.D.); the Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami (M.T.A.); and the Division of Gastroenterology, Third Department of Internal Medicine, Kyorin University School of Medicine, Tokyo (T.H.)
| | - Colleen Marano
- From the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York (B.E.S.); the Division of Gastroenterology, University of California, San Diego, La Jolla (W.J.S.), and the F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; the Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada (R.P.); Janssen Research and Development, Spring House, PA (C.D.O., H.Z., J.J., O.J.A., K.L., P.S., C.M.); the Gastroenterology Department and INSERM 1256, Nutrition, Genetics, and Environmental Risk Exposure, Nancy University Hospital, Université de Lorraine, Nancy, France (L.P.-B.); the Division of Gastroenterology and Hepatology, University Hospitals Leuven and Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium (G.V.A.); the IBD Center, Department of Gastroenterology, Humanitas Research Hospital and Humanitas University, Milan (S.D.); the Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami (M.T.A.); and the Division of Gastroenterology, Third Department of Internal Medicine, Kyorin University School of Medicine, Tokyo (T.H.)
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20
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Chang JY, Cheon JH. Thiopurine Therapy in Patients With Inflammatory Bowel Disease: A Focus on Metabolism and Pharmacogenetics. Dig Dis Sci 2019; 64:2395-2403. [PMID: 31290039 DOI: 10.1007/s10620-019-05720-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 07/02/2019] [Indexed: 12/15/2022]
Abstract
Thiopurines have been widely used for the maintenance of remission or steroid sparing in patients with inflammatory bowel disease. However, potential drug-related adverse events frequently interfere with their use. Indeed, drug withdrawals associated with adverse reactions have been reported in approximately 25% of patients. To balance the efficacy, safety, and tolerability of thiopurines, regular monitoring of biomarkers (complete blood cell count, liver function test, and metabolic profiles), steady dose escalation, and pretreatment thiopurine S-methyltransferase (TPMT) genotype screening have been routinely recommended. However, the complex thiopurine metabolic pathway and individual differences attributed to pharmacogenetic diversity limit the effectiveness of these strategies in the optimization of thiopurine therapy. Recently, in an effort to facilitate more accurate and personalized prediction of thiopurine response or toxicity, novel genetic markers including NUDT15 and FTO genes were discovered. These discoveries are remarkable because TPMT screening has minimal efficacy for predicting myelosuppression especially in Asian populations, despite the fact that thee populations have a higher frequency of myelosuppression than Western populations. This review focuses on the current understanding of the metabolic pathway and the pharmacogenetics of thiopurines and suggests a personalized preventive strategy against potential adverse drug reactions to optimize their therapeutic application.
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Affiliation(s)
- Ji Young Chang
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
- Department of Health Promotion Center, Ewha Womans University School of Medicine, Seoul, Korea
| | - Jae Hee Cheon
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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21
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Pudipeddi A, Kariyawasam V, Haifer C, Baraty B, Paramsothy S, Leong RWL. Safety of drugs used for the treatment of Crohn’s disease. Expert Opin Drug Saf 2019; 18:357-367. [PMID: 31026401 DOI: 10.1080/14740338.2019.1612874] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Medications in treating Crohn's disease (CD) have evolved over the last two decades, particularly with the use of biologic agents. There are, however, concerns about the safety and adverse events associated with these medications. The authors review the safety profile of immunosuppressive medications used in Crohn's disease in adult patients. AREAS COVERED The authors performed a literature search until October 2018 to examine safety data on thiopurines, methotrexate, anti-TNFα agents, vedolizumab and ustekinumab. The authors focused on 'trial' and 'real-world' data for the biologic agents. Safety in pregnancy and the elderly are also presented. EXPERT OPINION Available data in CD suggest that immunosuppressive medications are relatively safe, although there are concerns about an elevated risk of serious infections, skin cancer and lymphoma particularly with thiopurines and anti-TNFα agents. Data on vedolizumab and ustekinumab suggest these newer biologic agents are well tolerated; however, longer term data in CD are required to identify risks with extended use. Apart from methotrexate, there appear to be no adverse congenital outcomes with exposure of drugs during pregnancy.
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Affiliation(s)
- Aviv Pudipeddi
- Department of Gastroenterology and Liver Services, Concord Hospital, Sydney, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Viraj Kariyawasam
- Department of Gastroenterology and Liver Services, Concord Hospital, Sydney, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Craig Haifer
- Department of Gastroenterology and Liver Services, Concord Hospital, Sydney, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Brandon Baraty
- Department of Gastroenterology and Liver Services, Concord Hospital, Sydney, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Sudarshan Paramsothy
- Department of Gastroenterology and Liver Services, Concord Hospital, Sydney, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Rupert WL Leong
- Department of Gastroenterology and Liver Services, Concord Hospital, Sydney, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
- Faculty of Medicine, UNSW, Sydney, Australia
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22
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Özgenç F, Karakoyun M, Ecevit Ç, Hekimci H, Kıran Taşçı E, Erdemir G. Efficacy and safety of long-term thiopurine maintenance treatment for ulcerative colitis in Turkey: A single-center experience. TURKISH JOURNAL OF GASTROENTEROLOGY 2019; 29:650-654. [PMID: 30381272 DOI: 10.5152/tjg.2018.17151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND/AIMS Thiopurines are widely used in the treatment of inflammatory bowel disease, but data are limited. Or aim was to determine the outcome of thiopurine application in children diagnosed with ulcerative colitis (UC). MATERIALS AND METHODS Forty-eight patients with UC, diagnosed at our center between 2005 and 2016 and applied azathiopurine (AZA), were included in the study. Data were collected retrospectively. The diagnosis of UC was based on the conventional clinical, radiological, histological, and endoscopic assessment. All patients with UC at this intercept were analyzed at the 4- and 6-week and 3-month intervals after remission to determine patient characteristics, thiopurine properties, and its efficacy and toxicity. Determination of remission, relapse, and steroid refractoriness/dependency were guided according to the European Crohn's and Colitis Organisation consensus. RESULTS Azathiopurine was started at the median 1 month (0-12 months), and it was applied thereafter for maintenance (n=43). Response to remission induction was obtained in 40 (93.7%) patients. The median duration of the AZA treatment was 24 months (5-63). In 34 (85%) of the 40 children, it was well tolerated until the last visit. During the follow-up, adverse events occurred in 6 patients. These are leucopenia, neutropenia, vomiting, diarrhea, and skin rush. CONCLUSION Thiopurine is an appropriate treatment option for remission in patients with UC. For a long-term follow-up, it is very important to identify patients with UC who have clinical remission with side effects and with thiopurine application.
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Affiliation(s)
- Funda Özgenç
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Ege University School of Medicine, İzmir, Turkey
| | - Miray Karakoyun
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Tepecik Training and Research Hospital, İzmir, Turkey
| | - Çiğdem Ecevit
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Dr. Behçet Uz Children Hospital, İzmir, Turkey
| | - Hamiyet Hekimci
- Department of Pediatric Hematology, Ege University School of Medicine, İzmir, Turkey
| | - Ezgi Kıran Taşçı
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Ege University School of Medicine, İzmir, Turkey
| | - Gülin Erdemir
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Dr. Behçet Uz Children Hospital, İzmir, Turkey
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23
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Thunström Salzer A, Niemiec MJ, Hosseinzadeh A, Stylianou M, Åström F, Röhm M, Ahlm C, Wahlin A, Ermert D, Urban CF. Assessment of Neutrophil Chemotaxis Upon G-CSF Treatment of Healthy Stem Cell Donors and in Allogeneic Transplant Recipients. Front Immunol 2018; 9:1968. [PMID: 30254629 PMCID: PMC6141688 DOI: 10.3389/fimmu.2018.01968] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 08/10/2018] [Indexed: 12/15/2022] Open
Abstract
Neutrophils are crucial for the human innate immunity and constitute the majority of leukocytes in circulation. Thus, blood neutrophil counts serve as a measure for the immune system's functionality. Hematological patients often have low neutrophil counts due to disease or chemotherapy. To increase neutrophil counts and thereby preventing infections in high-risk patients, recombinant G-CSF is widely used as adjunct therapy to stimulate the maturation of neutrophils. In addition, G-CSF is utilized to recruit stem cells (SCs) into the peripheral blood of SC donors. Still, the actual functionality of neutrophils resulting from G-CSF treatment remains insufficiently understood. We tested the ex vivo functionality of neutrophils isolated from blood of G-CSF-treated healthy SC donors. We quantified chemotaxis, oxidative burst, and phagocytosis before and after treatment and detected significantly reduced chemotactic activity upon G-CSF treatment. Similarly, in vitro treatment of previously untreated neutrophils with G-CSF led to reduced chemotactic activity. In addition, we revealed that this effect persists in the allogeneic SC recipients up to 4 weeks after neutrophil engraftment. Our data indicates that neutrophil quantity, as a sole measure of immunocompetence in high-risk patients should be considered cautiously as neutrophil functionality might be affected by the primary treatment.
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Affiliation(s)
- Anna Thunström Salzer
- Department of Radiation Sciences, University of Umeå, Umeå, Sweden.,Department of Clinical Microbiology & Laboratory of Molecular Infection Medicine Sweden, Umeå University, Umeå, Sweden
| | - Maria J Niemiec
- Department of Clinical Microbiology & Laboratory of Molecular Infection Medicine Sweden, Umeå University, Umeå, Sweden
| | - Ava Hosseinzadeh
- Department of Clinical Microbiology & Laboratory of Molecular Infection Medicine Sweden, Umeå University, Umeå, Sweden
| | - Marios Stylianou
- Department of Clinical Microbiology & Laboratory of Molecular Infection Medicine Sweden, Umeå University, Umeå, Sweden
| | - Fredrik Åström
- Department of Radiation Sciences, University of Umeå, Umeå, Sweden
| | - Marc Röhm
- Department of Clinical Microbiology & Laboratory of Molecular Infection Medicine Sweden, Umeå University, Umeå, Sweden
| | - Clas Ahlm
- Department of Clinical Microbiology & Laboratory of Molecular Infection Medicine Sweden, Umeå University, Umeå, Sweden
| | - Anders Wahlin
- Department of Radiation Sciences, University of Umeå, Umeå, Sweden
| | - David Ermert
- Department of Clinical Microbiology & Laboratory of Molecular Infection Medicine Sweden, Umeå University, Umeå, Sweden
| | - Constantin F Urban
- Department of Clinical Microbiology & Laboratory of Molecular Infection Medicine Sweden, Umeå University, Umeå, Sweden
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24
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Can we move directly from 5-ASA to a biologic agent in ulcerative colitis? Best Pract Res Clin Gastroenterol 2018; 32-33:9-15. [PMID: 30060944 DOI: 10.1016/j.bpg.2018.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 05/03/2018] [Indexed: 01/31/2023]
Abstract
European consensus guidelines and reimbursement policies position biologic drugs for ulcerative colitis (UC) as a third-line treatment, after failure of 5-aminosalicylic acid (5-ASA) and corticosteroids/thiopurines. While 5-ASA have a very favorable safety profile, (prolonged) use of corticosteroids and thiopurines is associated with potentially serious adverse events. The therapeutic landscape of UC is rapidly evolving and selective biologic drugs with improved safety are being introduced. The first biosimilars have entered the market, leading to improved cost-effectiveness of older biologic drugs. In addition, new insights have been gained in the importance of stringent therapeutic targets such as mucosal and histological healing to improve the long-term outcome of UC patients, and in the role of therapeutic drug monitoring and treatment optimization in this regard. In this manuscript we tackle the question of whether we should move directly from 5-ASA treatment to biologic drugs to offer better and/or safer care to UC patients.
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25
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Stamatiades GA, Ioannou P, Petrikkos G, Tsioutis C. Fungal infections in patients with inflammatory bowel disease: A systematic review. Mycoses 2018; 61:366-376. [PMID: 29453860 DOI: 10.1111/myc.12753] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 02/03/2018] [Accepted: 02/03/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Despite reports of fungal infections in patients with inflammatory bowel disease (IBD), their clinical and microbiological characteristics remain unknown. OBJECTIVES The aim of this systematic review was to examine all available evidence regarding fungal infections in patients with IBD. METHODS Systematic search of PubMed (through 27 May 2017) for studies providing data on clinical, microbiological, treatment and outcome data of fungal infections in patients with IBD. The primary study outcome was to record the most common fungal species in patients with IBD. Secondary outcomes were classified into 3 categories: (i) characteristics of fungal infections; (ii) data on IBD and (iii) treatment and outcomes of fungal infections in patients with IBD. RESULTS Fourteen studies with data on 1524 patients were included in final analysis. The most common fungal infections in patients with IBD were caused by Candida species (903 infections); the most commonly reported site of Candida infection was the gastrointestinal tract. Available evidence shows that most fungal infections occur within 12 months of IBD treatment and within 6 months when anti-TNFa agents are used. CONCLUSIONS This systematic review thoroughly describes fungal infections in patients with IBD and provides important information for the early detection and management of these infections.
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Affiliation(s)
- George A Stamatiades
- Infectious Diseases Working Group, Society of Junior Doctors, Athens, Greece.,Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Petros Ioannou
- Infectious Diseases Working Group, Society of Junior Doctors, Athens, Greece.,Internal Medicine & Infectious Diseases Department, University Hospital of Heraklion, Heraklion, Greece
| | - George Petrikkos
- School of Medicine, European University of Cyprus, Nicosia, Cyprus
| | - Constantinos Tsioutis
- Infectious Diseases Working Group, Society of Junior Doctors, Athens, Greece.,School of Medicine, European University of Cyprus, Nicosia, Cyprus
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Capillary Electrophoresis Hyphenated with Mass Spectrometry for Determination of Inflammatory Bowel Disease Drugs in Clinical Urine Samples. Molecules 2017; 22:molecules22111973. [PMID: 29140288 PMCID: PMC6150202 DOI: 10.3390/molecules22111973] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 11/09/2017] [Accepted: 11/10/2017] [Indexed: 01/01/2023] Open
Abstract
Azathioprine is the main thiopurine drug used in the treatment of immune-based inflammations of gastrointestinal tract. For the purpose of therapy control and optimization, effective and reliable analytical methods for a rapid drug monitoring in biological fluids are essential. Here, we developed a separation method based on the capillary electrophoresis (CE) hyphenated with tandem mass spectrometry (MS/MS) for the simultaneous determination of azathioprine and its selected metabolites (6-thioguanine, 6-mercaptopurine, and 6-methylmercaptopurine) as well as other co-medicated drugs (mesalazine, prednisone, and allopurinol). The optimized CE-MS/MS conditions provided a very efficient and stable system for the separation and sensitive detection of these drugs in human urine matrices. The developed method was successfully applied for the assay of the targeted drugs and their selected metabolites in urine samples collected from patients suffering from inflammatory bowel disease (IBD) and receiving azathioprine therapy. The developed CE-MS/MS method, due to its reliability, short analysis time, production of complex clinical profiles, and favorable performance parameters, evaluated according to FDA guidelines for bioanalytical method validation, is proposed for routine clinical laboratories to optimize thiopurine therapy, estimate enzymatic activity, and control patient compliance with medication and co-medication.
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27
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Chapman S, El-Matary W. Screening for Epstein-Barr Virus Status and Risk of Hemophagocytic Lymphohistiocytosis in Children With Inflammatory Bowel Disease on Azathioprine. Gastroenterology 2017; 153:1167-1168. [PMID: 28881189 DOI: 10.1053/j.gastro.2017.07.052] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Accepted: 07/05/2017] [Indexed: 12/02/2022]
Affiliation(s)
- Stacy Chapman
- Section of Pediatric Gastroenterology, Department of Pediatrics, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Wael El-Matary
- Section of Pediatric Gastroenterology, Department of Pediatrics, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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de Carvalho OV, Félix DM, de Mendonça LR, de Araújo CMCS, de Oliveira Franca RF, Cordeiro MT, Silva Júnior A, Pena LJ. The thiopurine nucleoside analogue 6-methylmercaptopurine riboside (6MMPr) effectively blocks Zika virus replication. Int J Antimicrob Agents 2017; 50:718-725. [PMID: 28803932 DOI: 10.1016/j.ijantimicag.2017.08.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 07/05/2017] [Accepted: 08/05/2017] [Indexed: 10/19/2022]
Abstract
Since the emergence of Zika virus (ZIKV) in Brazil in 2015, 48 countries and territories in the Americas have confirmed autochthonous cases of disease caused by the virus. ZIKV-associated neurological manifestations and congenital defects make the development of safe and effective antivirals against ZIKV of utmost importance. Here we evaluated the antiviral activity of 6-methylmercaptopurine riboside (6MMPr), a thiopurine nucleoside analogue derived from the prodrug azathioprine, against the epidemic ZIKV strain circulating in Brazil. In all of the assays, an epithelial (Vero) and a human neuronal (SH-SY5Y) cell line were used to evaluate the cytotoxicity and effective concentrations of 6MMPr against ZIKV. Levels of ZIKV-RNA, viral infectious titre and the percentage of infected cells in the presence or absence of 6MMPr were used to determine antiviral efficacy. 6MMPr decreased ZIKV production by >99% in both cell lines in a dose- and time-dependent manner. Interestingly, 6MMPr was 1.6 times less toxic to SH-SY5Y cells compared with Vero cells, presenting a 50% cytotoxic concentrations (CC50) of 460.3 µM and 291 µM, respectively. The selectivity index of 6MMPr for Vero and SH-SY5Y cells was 11.9 and 22.7, respectively, highlighting the safety profile of the drug to neuronal cells. Taken together, these results identify, for the first time, the thiopurine nucleoside analogue 6MMPr as a promising antiviral candidate against ZIKV that warrants further in vivo evaluation.
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Affiliation(s)
- Otavio Valério de Carvalho
- Department of Virology, Oswaldo Cruz Foundation (Fiocruz), Avenida Professor Moraes Rego, Recife, Pernambuco, Brazil
| | - Daniele Mendes Félix
- Department of Virology, Oswaldo Cruz Foundation (Fiocruz), Avenida Professor Moraes Rego, Recife, Pernambuco, Brazil
| | - Leila Rodrigues de Mendonça
- Department of Virology, Oswaldo Cruz Foundation (Fiocruz), Avenida Professor Moraes Rego, Recife, Pernambuco, Brazil
| | | | | | - Marli Tenório Cordeiro
- Department of Virology, Oswaldo Cruz Foundation (Fiocruz), Avenida Professor Moraes Rego, Recife, Pernambuco, Brazil
| | - Abelardo Silva Júnior
- Department of Veterinary Medicine, Federal University of Viçosa (UFV), Av. PH Rolfs, s/n, Viçosa, Minas Gerais 36570-900, Brazil.
| | - Lindomar José Pena
- Department of Virology, Oswaldo Cruz Foundation (Fiocruz), Avenida Professor Moraes Rego, Recife, Pernambuco, Brazil.
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Biancone L, Annese V, Ardizzone S, Armuzzi A, Calabrese E, Caprioli F, Castiglione F, Comberlato M, Cottone M, Danese S, Daperno M, D'Incà R, Frieri G, Fries W, Gionchetti P, Kohn A, Latella G, Milla M, Orlando A, Papi C, Petruzziello C, Riegler G, Rizzello F, Saibeni S, Scribano ML, Vecchi M, Vernia P, Meucci G, Bossa F, Cappello M, Cassinotti A, Chiriatti A, Fiorino G, Formica V, Guidi L, Losco A, Mocciaro F, Onali S, Pastorelli L, Pica R, Principi M, Renna S, Ricci C, Rispo A, Rogai F, Sarmati L, Scaldaferri F, Spina L, Tambasco R, Testa A, Viscido A. Safety of treatments for inflammatory bowel disease: Clinical practice guidelines of the Italian Group for the Study of Inflammatory Bowel Disease (IG-IBD). Dig Liver Dis 2017; 49:338-358. [PMID: 28161290 DOI: 10.1016/j.dld.2017.01.141] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Revised: 12/19/2016] [Accepted: 01/07/2017] [Indexed: 02/08/2023]
Abstract
Inflammatory bowel diseases are chronic conditions of unknown etiology, showing a growing incidence and prevalence in several countries, including Italy. Although the etiology of Crohn's disease and ulcerative colitis is unknown, due to the current knowledge regarding their pathogenesis, effective treatment strategies have been developed. Several guidelines are available regarding the efficacy and safety of available drug treatments for inflammatory bowel diseases. Nevertheless, national guidelines provide additional information adapted to local feasibility, costs and legal issues related to the use of the same drugs. These observations prompted the Italian Group for the Study of Inflammatory Bowel Disease (IG-IBD) to establish Italian guidelines on the safety of currently available treatments for Crohn's disease and ulcerative colitis. These guidelines discuss the use of aminosalicylates, systemic and low bioavailability corticosteroids, antibiotics (metronidazole, ciprofloxacin, rifaximin), thiopurines, methotrexate, cyclosporine A, TNFα antagonists, vedolizumab, and combination therapies. These guidelines are based on current knowledge derived from evidence-based medicine coupled with clinical experience of a national working group.
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Affiliation(s)
- Livia Biancone
- Gastroenterology Unit, University of Rome "Tor Vergata", Department of Systems Medicine, Rome, Italy.
| | - Vito Annese
- AOU Careggi, Gastroenterology, Florence, Italy
| | - Sandro Ardizzone
- Gastrointestinal Unit, ASST Fatebenefratelli Sacco - University of Milan, Milan, Italy
| | - Alessandro Armuzzi
- IBD Unit, Presidio Columbus, Fondazione Policlinico Gemelli Universita' Cattolica, Rome, Italy
| | - Emma Calabrese
- Gastroenterology Unit, University of Rome "Tor Vergata", Department of Systems Medicine, Rome, Italy
| | - Flavio Caprioli
- Department of Pathophysiology and Transplantation, University of Milan and Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda,Ospedale Policlinico di Milano, Milan, Italy
| | | | - Michele Comberlato
- Department of Gastroenterology and Digestive Endoscopy, Central Hospital, Bolzano, Italy
| | - Mario Cottone
- Division of Internal Medicine 2, IBD Unit, Hospital "Riuniti Villa Sofia-Cervello", Palermo, Italy
| | - Silvio Danese
- Humanitas Research Hospital and Humanitas University, Rozzano (Milan), Italy
| | - Marco Daperno
- Hospital "Ordine Mauriziano di Torino", Turin, Italy
| | - Renata D'Incà
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Italy
| | - Giuseppe Frieri
- University of L'Aquila, Gastroenterology Unit, L'Aquila, Italy
| | - Walter Fries
- Department of Clinical and Experimental Medicine, Clinical Unit for Chroric Bowel Disorders, University of Messina, Messina, Italy
| | - Paolo Gionchetti
- IBD Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Anna Kohn
- San Camillo-Forlanini Hospital, IBD Unit, Rome, Italy
| | | | | | - Ambrogio Orlando
- Division of Internal Medicine 2, IBD Unit, Hospital "Riuniti Villa Sofia-Cervello", Palermo, Italy
| | - Claudio Papi
- IBD Unit, San Filippo Neri Hospital, Rome, Italy
| | - Carmelina Petruzziello
- Gastroenterology Unit, University of Rome "Tor Vergata", Department of Systems Medicine, Rome, Italy
| | - Gabriele Riegler
- U.O. of Gastroenterology C.S. - University della Campania "Luigi Vanvitelli", Naples, Italy
| | - Fernando Rizzello
- IBD Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Simone Saibeni
- Gastroenterology Unit, Rho Hospital, ASST Rhodense, Rho, Italy
| | | | - Maurizio Vecchi
- Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS Policlinico San Donato and University of Milan, San Donato Milanese, Milan, Italy
| | - Piero Vernia
- Gastroenterology Unit, Sapienza, University of Rome, Rome, Italy
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da Silva MB, da Cunha FF, Terra FF, Camara NOS. Old game, new players: Linking classical theories to new trends in transplant immunology. World J Transplant 2017; 7:1-25. [PMID: 28280691 PMCID: PMC5324024 DOI: 10.5500/wjt.v7.i1.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 11/16/2016] [Accepted: 12/07/2016] [Indexed: 02/05/2023] Open
Abstract
The evolutionary emergence of an efficient immune system has a fundamental role in our survival against pathogenic attacks. Nevertheless, this same protective mechanism may also establish a negative consequence in the setting of disorders such as autoimmunity and transplant rejection. In light of the latter, although research has long uncovered main concepts of allogeneic recognition, immune rejection is still the main obstacle to long-term graft survival. Therefore, in order to define effective therapies that prolong graft viability, it is essential that we understand the underlying mediators and mechanisms that participate in transplant rejection. This multifaceted process is characterized by diverse cellular and humoral participants with innate and adaptive functions that can determine the type of rejection or promote graft acceptance. Although a number of mediators of graft recognition have been described in traditional immunology, recent studies indicate that defining rigid roles for certain immune cells and factors may be more complicated than originally conceived. Current research has also targeted specific cells and drugs that regulate immune activation and induce tolerance. This review will give a broad view of the most recent understanding of the allogeneic inflammatory/tolerogenic response and current insights into cellular and drug therapies that modulate immune activation that may prove to be useful in the induction of tolerance in the clinical setting.
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Feagan BG, Sandborn WJ, Gasink C, Jacobstein D, Lang Y, Friedman JR, Blank MA, Johanns J, Gao LL, Miao Y, Adedokun OJ, Sands BE, Hanauer SB, Vermeire S, Targan S, Ghosh S, de Villiers WJ, Colombel JF, Tulassay Z, Seidler U, Salzberg BA, Desreumaux P, Lee SD, Loftus EV, Dieleman LA, Katz S, Rutgeerts P. Ustekinumab as Induction and Maintenance Therapy for Crohn's Disease. N Engl J Med 2016; 375:1946-1960. [PMID: 27959607 DOI: 10.1056/nejmoa1602773] [Citation(s) in RCA: 1152] [Impact Index Per Article: 144.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Ustekinumab, a monoclonal antibody to the p40 subunit of interleukin-12 and interleukin-23, was evaluated as an intravenous induction therapy in two populations with moderately to severely active Crohn's disease. Ustekinumab was also evaluated as subcutaneous maintenance therapy. METHODS We randomly assigned patients to receive a single intravenous dose of ustekinumab (either 130 mg or approximately 6 mg per kilogram of body weight) or placebo in two induction trials. The UNITI-1 trial included 741 patients who met the criteria for primary or secondary nonresponse to tumor necrosis factor (TNF) antagonists or had unacceptable side effects. The UNITI-2 trial included 628 patients in whom conventional therapy failed or unacceptable side effects occurred. Patients who completed these induction trials then participated in IM-UNITI, in which the 397 patients who had a response to ustekinumab were randomly assigned to receive subcutaneous maintenance injections of 90 mg of ustekinumab (either every 8 weeks or every 12 weeks) or placebo. The primary end point for the induction trials was a clinical response at week 6 (defined as a decrease from baseline in the Crohn's Disease Activity Index [CDAI] score of ≥100 points or a CDAI score <150). The primary end point for the maintenance trial was remission at week 44 (CDAI score <150). RESULTS The rates of response at week 6 among patients receiving intravenous ustekinumab at a dose of either 130 mg or approximately 6 mg per kilogram were significantly higher than the rates among patients receiving placebo (in UNITI-1, 34.3%, 33.7%, and 21.5%, respectively, with P≤0.003 for both comparisons with placebo; in UNITI-2, 51.7%, 55.5%, and 28.7%, respectively, with P<0.001 for both doses). In the groups receiving maintenance doses of ustekinumab every 8 weeks or every 12 weeks, 53.1% and 48.8%, respectively, were in remission at week 44, as compared with 35.9% of those receiving placebo (P=0.005 and P=0.04, respectively). Within each trial, adverse-event rates were similar among treatment groups. CONCLUSIONS Among patients with moderately to severely active Crohn's disease, those receiving intravenous ustekinumab had a significantly higher rate of response than did those receiving placebo. Subcutaneous ustekinumab maintained remission in patients who had a clinical response to induction therapy. (Funded by Janssen Research and Development; ClinicalTrials.gov numbers, NCT01369329 , NCT01369342 , and NCT01369355 .).
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Affiliation(s)
- Brian G Feagan
- From Robarts Clinical Trials, Robarts Research Institute, Western University, London, ON (B.G.F.), University of Calgary, Calgary, AB (S.G.), and the Division of Gastroenterology and CEGIIR, University of Alberta, Edmonton (L.A.D.) - all in Canada; University of California, San Diego, La Jolla (W.J.S.), and Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; Janssen Research and Development, Spring House (C.G., D.J., Y.L., J.R.F., J.J., L.-L.G., Y.M., O.J.A.), and Janssen Scientific Affairs, Horsham (M.A.B.) - both in Pennsylvania; the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai (B.E.S., J.-F.C.), and New York University School of Medicine (S.K.) - both in New York; Feinberg School of Medicine, Northwestern University, Chicago (S.B.H.); University Hospitals Leuven, Leuven, Belgium (S.V., P.R.); Stellenbosch University, Stellenbosch, South Africa (W.J.V.); Semmelweis University of Budapest, Budapest, Hungary (Z.T.); the Department of Gastroenterology, Hannover Medical School, Hannover, Germany (U.S.); Atlanta Gastroenterology Specialists, Atlanta (B.A.S.); Hôpital Claude Huriez, Lille, France (P.D.); University of Washington Medical Center, Seattle (S.D.L.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (E.V.L.)
| | - William J Sandborn
- From Robarts Clinical Trials, Robarts Research Institute, Western University, London, ON (B.G.F.), University of Calgary, Calgary, AB (S.G.), and the Division of Gastroenterology and CEGIIR, University of Alberta, Edmonton (L.A.D.) - all in Canada; University of California, San Diego, La Jolla (W.J.S.), and Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; Janssen Research and Development, Spring House (C.G., D.J., Y.L., J.R.F., J.J., L.-L.G., Y.M., O.J.A.), and Janssen Scientific Affairs, Horsham (M.A.B.) - both in Pennsylvania; the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai (B.E.S., J.-F.C.), and New York University School of Medicine (S.K.) - both in New York; Feinberg School of Medicine, Northwestern University, Chicago (S.B.H.); University Hospitals Leuven, Leuven, Belgium (S.V., P.R.); Stellenbosch University, Stellenbosch, South Africa (W.J.V.); Semmelweis University of Budapest, Budapest, Hungary (Z.T.); the Department of Gastroenterology, Hannover Medical School, Hannover, Germany (U.S.); Atlanta Gastroenterology Specialists, Atlanta (B.A.S.); Hôpital Claude Huriez, Lille, France (P.D.); University of Washington Medical Center, Seattle (S.D.L.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (E.V.L.)
| | - Christopher Gasink
- From Robarts Clinical Trials, Robarts Research Institute, Western University, London, ON (B.G.F.), University of Calgary, Calgary, AB (S.G.), and the Division of Gastroenterology and CEGIIR, University of Alberta, Edmonton (L.A.D.) - all in Canada; University of California, San Diego, La Jolla (W.J.S.), and Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; Janssen Research and Development, Spring House (C.G., D.J., Y.L., J.R.F., J.J., L.-L.G., Y.M., O.J.A.), and Janssen Scientific Affairs, Horsham (M.A.B.) - both in Pennsylvania; the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai (B.E.S., J.-F.C.), and New York University School of Medicine (S.K.) - both in New York; Feinberg School of Medicine, Northwestern University, Chicago (S.B.H.); University Hospitals Leuven, Leuven, Belgium (S.V., P.R.); Stellenbosch University, Stellenbosch, South Africa (W.J.V.); Semmelweis University of Budapest, Budapest, Hungary (Z.T.); the Department of Gastroenterology, Hannover Medical School, Hannover, Germany (U.S.); Atlanta Gastroenterology Specialists, Atlanta (B.A.S.); Hôpital Claude Huriez, Lille, France (P.D.); University of Washington Medical Center, Seattle (S.D.L.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (E.V.L.)
| | - Douglas Jacobstein
- From Robarts Clinical Trials, Robarts Research Institute, Western University, London, ON (B.G.F.), University of Calgary, Calgary, AB (S.G.), and the Division of Gastroenterology and CEGIIR, University of Alberta, Edmonton (L.A.D.) - all in Canada; University of California, San Diego, La Jolla (W.J.S.), and Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; Janssen Research and Development, Spring House (C.G., D.J., Y.L., J.R.F., J.J., L.-L.G., Y.M., O.J.A.), and Janssen Scientific Affairs, Horsham (M.A.B.) - both in Pennsylvania; the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai (B.E.S., J.-F.C.), and New York University School of Medicine (S.K.) - both in New York; Feinberg School of Medicine, Northwestern University, Chicago (S.B.H.); University Hospitals Leuven, Leuven, Belgium (S.V., P.R.); Stellenbosch University, Stellenbosch, South Africa (W.J.V.); Semmelweis University of Budapest, Budapest, Hungary (Z.T.); the Department of Gastroenterology, Hannover Medical School, Hannover, Germany (U.S.); Atlanta Gastroenterology Specialists, Atlanta (B.A.S.); Hôpital Claude Huriez, Lille, France (P.D.); University of Washington Medical Center, Seattle (S.D.L.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (E.V.L.)
| | - Yinghua Lang
- From Robarts Clinical Trials, Robarts Research Institute, Western University, London, ON (B.G.F.), University of Calgary, Calgary, AB (S.G.), and the Division of Gastroenterology and CEGIIR, University of Alberta, Edmonton (L.A.D.) - all in Canada; University of California, San Diego, La Jolla (W.J.S.), and Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; Janssen Research and Development, Spring House (C.G., D.J., Y.L., J.R.F., J.J., L.-L.G., Y.M., O.J.A.), and Janssen Scientific Affairs, Horsham (M.A.B.) - both in Pennsylvania; the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai (B.E.S., J.-F.C.), and New York University School of Medicine (S.K.) - both in New York; Feinberg School of Medicine, Northwestern University, Chicago (S.B.H.); University Hospitals Leuven, Leuven, Belgium (S.V., P.R.); Stellenbosch University, Stellenbosch, South Africa (W.J.V.); Semmelweis University of Budapest, Budapest, Hungary (Z.T.); the Department of Gastroenterology, Hannover Medical School, Hannover, Germany (U.S.); Atlanta Gastroenterology Specialists, Atlanta (B.A.S.); Hôpital Claude Huriez, Lille, France (P.D.); University of Washington Medical Center, Seattle (S.D.L.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (E.V.L.)
| | - Joshua R Friedman
- From Robarts Clinical Trials, Robarts Research Institute, Western University, London, ON (B.G.F.), University of Calgary, Calgary, AB (S.G.), and the Division of Gastroenterology and CEGIIR, University of Alberta, Edmonton (L.A.D.) - all in Canada; University of California, San Diego, La Jolla (W.J.S.), and Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; Janssen Research and Development, Spring House (C.G., D.J., Y.L., J.R.F., J.J., L.-L.G., Y.M., O.J.A.), and Janssen Scientific Affairs, Horsham (M.A.B.) - both in Pennsylvania; the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai (B.E.S., J.-F.C.), and New York University School of Medicine (S.K.) - both in New York; Feinberg School of Medicine, Northwestern University, Chicago (S.B.H.); University Hospitals Leuven, Leuven, Belgium (S.V., P.R.); Stellenbosch University, Stellenbosch, South Africa (W.J.V.); Semmelweis University of Budapest, Budapest, Hungary (Z.T.); the Department of Gastroenterology, Hannover Medical School, Hannover, Germany (U.S.); Atlanta Gastroenterology Specialists, Atlanta (B.A.S.); Hôpital Claude Huriez, Lille, France (P.D.); University of Washington Medical Center, Seattle (S.D.L.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (E.V.L.)
| | - Marion A Blank
- From Robarts Clinical Trials, Robarts Research Institute, Western University, London, ON (B.G.F.), University of Calgary, Calgary, AB (S.G.), and the Division of Gastroenterology and CEGIIR, University of Alberta, Edmonton (L.A.D.) - all in Canada; University of California, San Diego, La Jolla (W.J.S.), and Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; Janssen Research and Development, Spring House (C.G., D.J., Y.L., J.R.F., J.J., L.-L.G., Y.M., O.J.A.), and Janssen Scientific Affairs, Horsham (M.A.B.) - both in Pennsylvania; the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai (B.E.S., J.-F.C.), and New York University School of Medicine (S.K.) - both in New York; Feinberg School of Medicine, Northwestern University, Chicago (S.B.H.); University Hospitals Leuven, Leuven, Belgium (S.V., P.R.); Stellenbosch University, Stellenbosch, South Africa (W.J.V.); Semmelweis University of Budapest, Budapest, Hungary (Z.T.); the Department of Gastroenterology, Hannover Medical School, Hannover, Germany (U.S.); Atlanta Gastroenterology Specialists, Atlanta (B.A.S.); Hôpital Claude Huriez, Lille, France (P.D.); University of Washington Medical Center, Seattle (S.D.L.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (E.V.L.)
| | - Jewel Johanns
- From Robarts Clinical Trials, Robarts Research Institute, Western University, London, ON (B.G.F.), University of Calgary, Calgary, AB (S.G.), and the Division of Gastroenterology and CEGIIR, University of Alberta, Edmonton (L.A.D.) - all in Canada; University of California, San Diego, La Jolla (W.J.S.), and Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; Janssen Research and Development, Spring House (C.G., D.J., Y.L., J.R.F., J.J., L.-L.G., Y.M., O.J.A.), and Janssen Scientific Affairs, Horsham (M.A.B.) - both in Pennsylvania; the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai (B.E.S., J.-F.C.), and New York University School of Medicine (S.K.) - both in New York; Feinberg School of Medicine, Northwestern University, Chicago (S.B.H.); University Hospitals Leuven, Leuven, Belgium (S.V., P.R.); Stellenbosch University, Stellenbosch, South Africa (W.J.V.); Semmelweis University of Budapest, Budapest, Hungary (Z.T.); the Department of Gastroenterology, Hannover Medical School, Hannover, Germany (U.S.); Atlanta Gastroenterology Specialists, Atlanta (B.A.S.); Hôpital Claude Huriez, Lille, France (P.D.); University of Washington Medical Center, Seattle (S.D.L.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (E.V.L.)
| | - Long-Long Gao
- From Robarts Clinical Trials, Robarts Research Institute, Western University, London, ON (B.G.F.), University of Calgary, Calgary, AB (S.G.), and the Division of Gastroenterology and CEGIIR, University of Alberta, Edmonton (L.A.D.) - all in Canada; University of California, San Diego, La Jolla (W.J.S.), and Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; Janssen Research and Development, Spring House (C.G., D.J., Y.L., J.R.F., J.J., L.-L.G., Y.M., O.J.A.), and Janssen Scientific Affairs, Horsham (M.A.B.) - both in Pennsylvania; the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai (B.E.S., J.-F.C.), and New York University School of Medicine (S.K.) - both in New York; Feinberg School of Medicine, Northwestern University, Chicago (S.B.H.); University Hospitals Leuven, Leuven, Belgium (S.V., P.R.); Stellenbosch University, Stellenbosch, South Africa (W.J.V.); Semmelweis University of Budapest, Budapest, Hungary (Z.T.); the Department of Gastroenterology, Hannover Medical School, Hannover, Germany (U.S.); Atlanta Gastroenterology Specialists, Atlanta (B.A.S.); Hôpital Claude Huriez, Lille, France (P.D.); University of Washington Medical Center, Seattle (S.D.L.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (E.V.L.)
| | - Ye Miao
- From Robarts Clinical Trials, Robarts Research Institute, Western University, London, ON (B.G.F.), University of Calgary, Calgary, AB (S.G.), and the Division of Gastroenterology and CEGIIR, University of Alberta, Edmonton (L.A.D.) - all in Canada; University of California, San Diego, La Jolla (W.J.S.), and Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; Janssen Research and Development, Spring House (C.G., D.J., Y.L., J.R.F., J.J., L.-L.G., Y.M., O.J.A.), and Janssen Scientific Affairs, Horsham (M.A.B.) - both in Pennsylvania; the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai (B.E.S., J.-F.C.), and New York University School of Medicine (S.K.) - both in New York; Feinberg School of Medicine, Northwestern University, Chicago (S.B.H.); University Hospitals Leuven, Leuven, Belgium (S.V., P.R.); Stellenbosch University, Stellenbosch, South Africa (W.J.V.); Semmelweis University of Budapest, Budapest, Hungary (Z.T.); the Department of Gastroenterology, Hannover Medical School, Hannover, Germany (U.S.); Atlanta Gastroenterology Specialists, Atlanta (B.A.S.); Hôpital Claude Huriez, Lille, France (P.D.); University of Washington Medical Center, Seattle (S.D.L.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (E.V.L.)
| | - Omoniyi J Adedokun
- From Robarts Clinical Trials, Robarts Research Institute, Western University, London, ON (B.G.F.), University of Calgary, Calgary, AB (S.G.), and the Division of Gastroenterology and CEGIIR, University of Alberta, Edmonton (L.A.D.) - all in Canada; University of California, San Diego, La Jolla (W.J.S.), and Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; Janssen Research and Development, Spring House (C.G., D.J., Y.L., J.R.F., J.J., L.-L.G., Y.M., O.J.A.), and Janssen Scientific Affairs, Horsham (M.A.B.) - both in Pennsylvania; the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai (B.E.S., J.-F.C.), and New York University School of Medicine (S.K.) - both in New York; Feinberg School of Medicine, Northwestern University, Chicago (S.B.H.); University Hospitals Leuven, Leuven, Belgium (S.V., P.R.); Stellenbosch University, Stellenbosch, South Africa (W.J.V.); Semmelweis University of Budapest, Budapest, Hungary (Z.T.); the Department of Gastroenterology, Hannover Medical School, Hannover, Germany (U.S.); Atlanta Gastroenterology Specialists, Atlanta (B.A.S.); Hôpital Claude Huriez, Lille, France (P.D.); University of Washington Medical Center, Seattle (S.D.L.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (E.V.L.)
| | - Bruce E Sands
- From Robarts Clinical Trials, Robarts Research Institute, Western University, London, ON (B.G.F.), University of Calgary, Calgary, AB (S.G.), and the Division of Gastroenterology and CEGIIR, University of Alberta, Edmonton (L.A.D.) - all in Canada; University of California, San Diego, La Jolla (W.J.S.), and Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; Janssen Research and Development, Spring House (C.G., D.J., Y.L., J.R.F., J.J., L.-L.G., Y.M., O.J.A.), and Janssen Scientific Affairs, Horsham (M.A.B.) - both in Pennsylvania; the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai (B.E.S., J.-F.C.), and New York University School of Medicine (S.K.) - both in New York; Feinberg School of Medicine, Northwestern University, Chicago (S.B.H.); University Hospitals Leuven, Leuven, Belgium (S.V., P.R.); Stellenbosch University, Stellenbosch, South Africa (W.J.V.); Semmelweis University of Budapest, Budapest, Hungary (Z.T.); the Department of Gastroenterology, Hannover Medical School, Hannover, Germany (U.S.); Atlanta Gastroenterology Specialists, Atlanta (B.A.S.); Hôpital Claude Huriez, Lille, France (P.D.); University of Washington Medical Center, Seattle (S.D.L.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (E.V.L.)
| | - Stephen B Hanauer
- From Robarts Clinical Trials, Robarts Research Institute, Western University, London, ON (B.G.F.), University of Calgary, Calgary, AB (S.G.), and the Division of Gastroenterology and CEGIIR, University of Alberta, Edmonton (L.A.D.) - all in Canada; University of California, San Diego, La Jolla (W.J.S.), and Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; Janssen Research and Development, Spring House (C.G., D.J., Y.L., J.R.F., J.J., L.-L.G., Y.M., O.J.A.), and Janssen Scientific Affairs, Horsham (M.A.B.) - both in Pennsylvania; the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai (B.E.S., J.-F.C.), and New York University School of Medicine (S.K.) - both in New York; Feinberg School of Medicine, Northwestern University, Chicago (S.B.H.); University Hospitals Leuven, Leuven, Belgium (S.V., P.R.); Stellenbosch University, Stellenbosch, South Africa (W.J.V.); Semmelweis University of Budapest, Budapest, Hungary (Z.T.); the Department of Gastroenterology, Hannover Medical School, Hannover, Germany (U.S.); Atlanta Gastroenterology Specialists, Atlanta (B.A.S.); Hôpital Claude Huriez, Lille, France (P.D.); University of Washington Medical Center, Seattle (S.D.L.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (E.V.L.)
| | - Severine Vermeire
- From Robarts Clinical Trials, Robarts Research Institute, Western University, London, ON (B.G.F.), University of Calgary, Calgary, AB (S.G.), and the Division of Gastroenterology and CEGIIR, University of Alberta, Edmonton (L.A.D.) - all in Canada; University of California, San Diego, La Jolla (W.J.S.), and Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; Janssen Research and Development, Spring House (C.G., D.J., Y.L., J.R.F., J.J., L.-L.G., Y.M., O.J.A.), and Janssen Scientific Affairs, Horsham (M.A.B.) - both in Pennsylvania; the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai (B.E.S., J.-F.C.), and New York University School of Medicine (S.K.) - both in New York; Feinberg School of Medicine, Northwestern University, Chicago (S.B.H.); University Hospitals Leuven, Leuven, Belgium (S.V., P.R.); Stellenbosch University, Stellenbosch, South Africa (W.J.V.); Semmelweis University of Budapest, Budapest, Hungary (Z.T.); the Department of Gastroenterology, Hannover Medical School, Hannover, Germany (U.S.); Atlanta Gastroenterology Specialists, Atlanta (B.A.S.); Hôpital Claude Huriez, Lille, France (P.D.); University of Washington Medical Center, Seattle (S.D.L.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (E.V.L.)
| | - Stephan Targan
- From Robarts Clinical Trials, Robarts Research Institute, Western University, London, ON (B.G.F.), University of Calgary, Calgary, AB (S.G.), and the Division of Gastroenterology and CEGIIR, University of Alberta, Edmonton (L.A.D.) - all in Canada; University of California, San Diego, La Jolla (W.J.S.), and Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; Janssen Research and Development, Spring House (C.G., D.J., Y.L., J.R.F., J.J., L.-L.G., Y.M., O.J.A.), and Janssen Scientific Affairs, Horsham (M.A.B.) - both in Pennsylvania; the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai (B.E.S., J.-F.C.), and New York University School of Medicine (S.K.) - both in New York; Feinberg School of Medicine, Northwestern University, Chicago (S.B.H.); University Hospitals Leuven, Leuven, Belgium (S.V., P.R.); Stellenbosch University, Stellenbosch, South Africa (W.J.V.); Semmelweis University of Budapest, Budapest, Hungary (Z.T.); the Department of Gastroenterology, Hannover Medical School, Hannover, Germany (U.S.); Atlanta Gastroenterology Specialists, Atlanta (B.A.S.); Hôpital Claude Huriez, Lille, France (P.D.); University of Washington Medical Center, Seattle (S.D.L.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (E.V.L.)
| | - Subrata Ghosh
- From Robarts Clinical Trials, Robarts Research Institute, Western University, London, ON (B.G.F.), University of Calgary, Calgary, AB (S.G.), and the Division of Gastroenterology and CEGIIR, University of Alberta, Edmonton (L.A.D.) - all in Canada; University of California, San Diego, La Jolla (W.J.S.), and Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; Janssen Research and Development, Spring House (C.G., D.J., Y.L., J.R.F., J.J., L.-L.G., Y.M., O.J.A.), and Janssen Scientific Affairs, Horsham (M.A.B.) - both in Pennsylvania; the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai (B.E.S., J.-F.C.), and New York University School of Medicine (S.K.) - both in New York; Feinberg School of Medicine, Northwestern University, Chicago (S.B.H.); University Hospitals Leuven, Leuven, Belgium (S.V., P.R.); Stellenbosch University, Stellenbosch, South Africa (W.J.V.); Semmelweis University of Budapest, Budapest, Hungary (Z.T.); the Department of Gastroenterology, Hannover Medical School, Hannover, Germany (U.S.); Atlanta Gastroenterology Specialists, Atlanta (B.A.S.); Hôpital Claude Huriez, Lille, France (P.D.); University of Washington Medical Center, Seattle (S.D.L.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (E.V.L.)
| | - Willem J de Villiers
- From Robarts Clinical Trials, Robarts Research Institute, Western University, London, ON (B.G.F.), University of Calgary, Calgary, AB (S.G.), and the Division of Gastroenterology and CEGIIR, University of Alberta, Edmonton (L.A.D.) - all in Canada; University of California, San Diego, La Jolla (W.J.S.), and Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; Janssen Research and Development, Spring House (C.G., D.J., Y.L., J.R.F., J.J., L.-L.G., Y.M., O.J.A.), and Janssen Scientific Affairs, Horsham (M.A.B.) - both in Pennsylvania; the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai (B.E.S., J.-F.C.), and New York University School of Medicine (S.K.) - both in New York; Feinberg School of Medicine, Northwestern University, Chicago (S.B.H.); University Hospitals Leuven, Leuven, Belgium (S.V., P.R.); Stellenbosch University, Stellenbosch, South Africa (W.J.V.); Semmelweis University of Budapest, Budapest, Hungary (Z.T.); the Department of Gastroenterology, Hannover Medical School, Hannover, Germany (U.S.); Atlanta Gastroenterology Specialists, Atlanta (B.A.S.); Hôpital Claude Huriez, Lille, France (P.D.); University of Washington Medical Center, Seattle (S.D.L.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (E.V.L.)
| | - Jean-Frédéric Colombel
- From Robarts Clinical Trials, Robarts Research Institute, Western University, London, ON (B.G.F.), University of Calgary, Calgary, AB (S.G.), and the Division of Gastroenterology and CEGIIR, University of Alberta, Edmonton (L.A.D.) - all in Canada; University of California, San Diego, La Jolla (W.J.S.), and Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; Janssen Research and Development, Spring House (C.G., D.J., Y.L., J.R.F., J.J., L.-L.G., Y.M., O.J.A.), and Janssen Scientific Affairs, Horsham (M.A.B.) - both in Pennsylvania; the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai (B.E.S., J.-F.C.), and New York University School of Medicine (S.K.) - both in New York; Feinberg School of Medicine, Northwestern University, Chicago (S.B.H.); University Hospitals Leuven, Leuven, Belgium (S.V., P.R.); Stellenbosch University, Stellenbosch, South Africa (W.J.V.); Semmelweis University of Budapest, Budapest, Hungary (Z.T.); the Department of Gastroenterology, Hannover Medical School, Hannover, Germany (U.S.); Atlanta Gastroenterology Specialists, Atlanta (B.A.S.); Hôpital Claude Huriez, Lille, France (P.D.); University of Washington Medical Center, Seattle (S.D.L.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (E.V.L.)
| | - Zsolt Tulassay
- From Robarts Clinical Trials, Robarts Research Institute, Western University, London, ON (B.G.F.), University of Calgary, Calgary, AB (S.G.), and the Division of Gastroenterology and CEGIIR, University of Alberta, Edmonton (L.A.D.) - all in Canada; University of California, San Diego, La Jolla (W.J.S.), and Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; Janssen Research and Development, Spring House (C.G., D.J., Y.L., J.R.F., J.J., L.-L.G., Y.M., O.J.A.), and Janssen Scientific Affairs, Horsham (M.A.B.) - both in Pennsylvania; the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai (B.E.S., J.-F.C.), and New York University School of Medicine (S.K.) - both in New York; Feinberg School of Medicine, Northwestern University, Chicago (S.B.H.); University Hospitals Leuven, Leuven, Belgium (S.V., P.R.); Stellenbosch University, Stellenbosch, South Africa (W.J.V.); Semmelweis University of Budapest, Budapest, Hungary (Z.T.); the Department of Gastroenterology, Hannover Medical School, Hannover, Germany (U.S.); Atlanta Gastroenterology Specialists, Atlanta (B.A.S.); Hôpital Claude Huriez, Lille, France (P.D.); University of Washington Medical Center, Seattle (S.D.L.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (E.V.L.)
| | - Ursula Seidler
- From Robarts Clinical Trials, Robarts Research Institute, Western University, London, ON (B.G.F.), University of Calgary, Calgary, AB (S.G.), and the Division of Gastroenterology and CEGIIR, University of Alberta, Edmonton (L.A.D.) - all in Canada; University of California, San Diego, La Jolla (W.J.S.), and Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; Janssen Research and Development, Spring House (C.G., D.J., Y.L., J.R.F., J.J., L.-L.G., Y.M., O.J.A.), and Janssen Scientific Affairs, Horsham (M.A.B.) - both in Pennsylvania; the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai (B.E.S., J.-F.C.), and New York University School of Medicine (S.K.) - both in New York; Feinberg School of Medicine, Northwestern University, Chicago (S.B.H.); University Hospitals Leuven, Leuven, Belgium (S.V., P.R.); Stellenbosch University, Stellenbosch, South Africa (W.J.V.); Semmelweis University of Budapest, Budapest, Hungary (Z.T.); the Department of Gastroenterology, Hannover Medical School, Hannover, Germany (U.S.); Atlanta Gastroenterology Specialists, Atlanta (B.A.S.); Hôpital Claude Huriez, Lille, France (P.D.); University of Washington Medical Center, Seattle (S.D.L.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (E.V.L.)
| | - Bruce A Salzberg
- From Robarts Clinical Trials, Robarts Research Institute, Western University, London, ON (B.G.F.), University of Calgary, Calgary, AB (S.G.), and the Division of Gastroenterology and CEGIIR, University of Alberta, Edmonton (L.A.D.) - all in Canada; University of California, San Diego, La Jolla (W.J.S.), and Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; Janssen Research and Development, Spring House (C.G., D.J., Y.L., J.R.F., J.J., L.-L.G., Y.M., O.J.A.), and Janssen Scientific Affairs, Horsham (M.A.B.) - both in Pennsylvania; the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai (B.E.S., J.-F.C.), and New York University School of Medicine (S.K.) - both in New York; Feinberg School of Medicine, Northwestern University, Chicago (S.B.H.); University Hospitals Leuven, Leuven, Belgium (S.V., P.R.); Stellenbosch University, Stellenbosch, South Africa (W.J.V.); Semmelweis University of Budapest, Budapest, Hungary (Z.T.); the Department of Gastroenterology, Hannover Medical School, Hannover, Germany (U.S.); Atlanta Gastroenterology Specialists, Atlanta (B.A.S.); Hôpital Claude Huriez, Lille, France (P.D.); University of Washington Medical Center, Seattle (S.D.L.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (E.V.L.)
| | - Pierre Desreumaux
- From Robarts Clinical Trials, Robarts Research Institute, Western University, London, ON (B.G.F.), University of Calgary, Calgary, AB (S.G.), and the Division of Gastroenterology and CEGIIR, University of Alberta, Edmonton (L.A.D.) - all in Canada; University of California, San Diego, La Jolla (W.J.S.), and Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; Janssen Research and Development, Spring House (C.G., D.J., Y.L., J.R.F., J.J., L.-L.G., Y.M., O.J.A.), and Janssen Scientific Affairs, Horsham (M.A.B.) - both in Pennsylvania; the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai (B.E.S., J.-F.C.), and New York University School of Medicine (S.K.) - both in New York; Feinberg School of Medicine, Northwestern University, Chicago (S.B.H.); University Hospitals Leuven, Leuven, Belgium (S.V., P.R.); Stellenbosch University, Stellenbosch, South Africa (W.J.V.); Semmelweis University of Budapest, Budapest, Hungary (Z.T.); the Department of Gastroenterology, Hannover Medical School, Hannover, Germany (U.S.); Atlanta Gastroenterology Specialists, Atlanta (B.A.S.); Hôpital Claude Huriez, Lille, France (P.D.); University of Washington Medical Center, Seattle (S.D.L.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (E.V.L.)
| | - Scott D Lee
- From Robarts Clinical Trials, Robarts Research Institute, Western University, London, ON (B.G.F.), University of Calgary, Calgary, AB (S.G.), and the Division of Gastroenterology and CEGIIR, University of Alberta, Edmonton (L.A.D.) - all in Canada; University of California, San Diego, La Jolla (W.J.S.), and Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; Janssen Research and Development, Spring House (C.G., D.J., Y.L., J.R.F., J.J., L.-L.G., Y.M., O.J.A.), and Janssen Scientific Affairs, Horsham (M.A.B.) - both in Pennsylvania; the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai (B.E.S., J.-F.C.), and New York University School of Medicine (S.K.) - both in New York; Feinberg School of Medicine, Northwestern University, Chicago (S.B.H.); University Hospitals Leuven, Leuven, Belgium (S.V., P.R.); Stellenbosch University, Stellenbosch, South Africa (W.J.V.); Semmelweis University of Budapest, Budapest, Hungary (Z.T.); the Department of Gastroenterology, Hannover Medical School, Hannover, Germany (U.S.); Atlanta Gastroenterology Specialists, Atlanta (B.A.S.); Hôpital Claude Huriez, Lille, France (P.D.); University of Washington Medical Center, Seattle (S.D.L.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (E.V.L.)
| | - Edward V Loftus
- From Robarts Clinical Trials, Robarts Research Institute, Western University, London, ON (B.G.F.), University of Calgary, Calgary, AB (S.G.), and the Division of Gastroenterology and CEGIIR, University of Alberta, Edmonton (L.A.D.) - all in Canada; University of California, San Diego, La Jolla (W.J.S.), and Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; Janssen Research and Development, Spring House (C.G., D.J., Y.L., J.R.F., J.J., L.-L.G., Y.M., O.J.A.), and Janssen Scientific Affairs, Horsham (M.A.B.) - both in Pennsylvania; the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai (B.E.S., J.-F.C.), and New York University School of Medicine (S.K.) - both in New York; Feinberg School of Medicine, Northwestern University, Chicago (S.B.H.); University Hospitals Leuven, Leuven, Belgium (S.V., P.R.); Stellenbosch University, Stellenbosch, South Africa (W.J.V.); Semmelweis University of Budapest, Budapest, Hungary (Z.T.); the Department of Gastroenterology, Hannover Medical School, Hannover, Germany (U.S.); Atlanta Gastroenterology Specialists, Atlanta (B.A.S.); Hôpital Claude Huriez, Lille, France (P.D.); University of Washington Medical Center, Seattle (S.D.L.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (E.V.L.)
| | - Levinus A Dieleman
- From Robarts Clinical Trials, Robarts Research Institute, Western University, London, ON (B.G.F.), University of Calgary, Calgary, AB (S.G.), and the Division of Gastroenterology and CEGIIR, University of Alberta, Edmonton (L.A.D.) - all in Canada; University of California, San Diego, La Jolla (W.J.S.), and Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; Janssen Research and Development, Spring House (C.G., D.J., Y.L., J.R.F., J.J., L.-L.G., Y.M., O.J.A.), and Janssen Scientific Affairs, Horsham (M.A.B.) - both in Pennsylvania; the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai (B.E.S., J.-F.C.), and New York University School of Medicine (S.K.) - both in New York; Feinberg School of Medicine, Northwestern University, Chicago (S.B.H.); University Hospitals Leuven, Leuven, Belgium (S.V., P.R.); Stellenbosch University, Stellenbosch, South Africa (W.J.V.); Semmelweis University of Budapest, Budapest, Hungary (Z.T.); the Department of Gastroenterology, Hannover Medical School, Hannover, Germany (U.S.); Atlanta Gastroenterology Specialists, Atlanta (B.A.S.); Hôpital Claude Huriez, Lille, France (P.D.); University of Washington Medical Center, Seattle (S.D.L.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (E.V.L.)
| | - Seymour Katz
- From Robarts Clinical Trials, Robarts Research Institute, Western University, London, ON (B.G.F.), University of Calgary, Calgary, AB (S.G.), and the Division of Gastroenterology and CEGIIR, University of Alberta, Edmonton (L.A.D.) - all in Canada; University of California, San Diego, La Jolla (W.J.S.), and Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; Janssen Research and Development, Spring House (C.G., D.J., Y.L., J.R.F., J.J., L.-L.G., Y.M., O.J.A.), and Janssen Scientific Affairs, Horsham (M.A.B.) - both in Pennsylvania; the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai (B.E.S., J.-F.C.), and New York University School of Medicine (S.K.) - both in New York; Feinberg School of Medicine, Northwestern University, Chicago (S.B.H.); University Hospitals Leuven, Leuven, Belgium (S.V., P.R.); Stellenbosch University, Stellenbosch, South Africa (W.J.V.); Semmelweis University of Budapest, Budapest, Hungary (Z.T.); the Department of Gastroenterology, Hannover Medical School, Hannover, Germany (U.S.); Atlanta Gastroenterology Specialists, Atlanta (B.A.S.); Hôpital Claude Huriez, Lille, France (P.D.); University of Washington Medical Center, Seattle (S.D.L.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (E.V.L.)
| | - Paul Rutgeerts
- From Robarts Clinical Trials, Robarts Research Institute, Western University, London, ON (B.G.F.), University of Calgary, Calgary, AB (S.G.), and the Division of Gastroenterology and CEGIIR, University of Alberta, Edmonton (L.A.D.) - all in Canada; University of California, San Diego, La Jolla (W.J.S.), and Cedars-Sinai Medical Center, Los Angeles (S.T.) - both in California; Janssen Research and Development, Spring House (C.G., D.J., Y.L., J.R.F., J.J., L.-L.G., Y.M., O.J.A.), and Janssen Scientific Affairs, Horsham (M.A.B.) - both in Pennsylvania; the Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai (B.E.S., J.-F.C.), and New York University School of Medicine (S.K.) - both in New York; Feinberg School of Medicine, Northwestern University, Chicago (S.B.H.); University Hospitals Leuven, Leuven, Belgium (S.V., P.R.); Stellenbosch University, Stellenbosch, South Africa (W.J.V.); Semmelweis University of Budapest, Budapest, Hungary (Z.T.); the Department of Gastroenterology, Hannover Medical School, Hannover, Germany (U.S.); Atlanta Gastroenterology Specialists, Atlanta (B.A.S.); Hôpital Claude Huriez, Lille, France (P.D.); University of Washington Medical Center, Seattle (S.D.L.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (E.V.L.)
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Vikse J, Cacic DL, Carlsen A, Cooper TJ, Grimstad T. A man in his 30s with ulcerative colitis and pancytopenia. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2016; 136:1010-4. [PMID: 27325035 DOI: 10.4045/tidsskr.15.0958] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
| | - Daniel Limi Cacic
- Avdeling for blod og kreftsykdommer Medisinsk divisjon Stavanger universitetssjukehus
| | - Arne Carlsen
- Gastroenterologisk seksjon Medisinsk divisjon Stavanger universitetssjukehus
| | - Trond Johan Cooper
- Infeksjonsmedisinsk seksjon Medisinsk divisjon Stavanger universitetssjukehus
| | - Tore Grimstad
- Gastroenterologisk seksjon Medisinsk divisjon Stavanger universitetssjukehus
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Vögelin M, Biedermann L, Frei P, Vavricka SR, Scharl S, Zeitz J, Sulz MC, Fried M, Rogler G, Scharl M. The Impact of Azathioprine-Associated Lymphopenia on the Onset of Opportunistic Infections in Patients with Inflammatory Bowel Disease. PLoS One 2016; 11:e0155218. [PMID: 27214202 PMCID: PMC4877071 DOI: 10.1371/journal.pone.0155218] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 04/26/2016] [Indexed: 12/18/2022] Open
Abstract
Background Thiopurines are known to cause lymphopenia (<1,500 lymphocytes/μl). As severe lymphopenia (<500C/μl) is associated with opportunistic infections, we investigated severity of thiopurine-related lymphopenia and development of opportunistic infections in our tertiary referral centre. Methods We retrospectively screened medical records of 1,070 IBD patients and identified 100 individuals that developed a total of 161 episodes of lymphopenia during thiopurine treatment between 2002 and 2014. Occurrence of opportunistic infections was documented. A control group consisted of IBD patients receiving thiopurines but without developing lymphopenia. Results Of a total of 161 episodes of lymphopenia, 23% were severe (<500C/μl). In this subgroup, thiopurine dosing was modified in 64% (dosage reduction: 32%, medication discontinued: 32%). We identified 9 cases (5.5%) of opportunistic infections, of which only two occurred during severe lymphopenia. One opportunistic infection (4.5%) was identified in the control group. No association was found between opportunistic infections and severity of lymphopenia. All patients who suffered from opportunistic infections were receiving additional immunosuppressive medication. Conclusion Our patients treated with thiopurines rarely developed severe lymphopenia and opportunistic infections did not occur more often than in the control group. A careful monitoring of lymphocytes and prophylactic adjustment of thiopurine therapy might contribute to this low incidence.
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Affiliation(s)
- Marius Vögelin
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Luc Biedermann
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Pascal Frei
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Stephan R. Vavricka
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Division of Gastroenterology and Hepatology, Stadtspital Triemli, Zurich, Switzerland
- Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
| | - Sylvie Scharl
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Jonas Zeitz
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Michael C. Sulz
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Division of Gastroenterology and Hepatology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Michael Fried
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Division of Gastroenterology and Hepatology, Stadtspital Triemli, Zurich, Switzerland
| | - Gerhard Rogler
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Division of Gastroenterology and Hepatology, Stadtspital Triemli, Zurich, Switzerland
| | - Michael Scharl
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Division of Gastroenterology and Hepatology, Stadtspital Triemli, Zurich, Switzerland
- * E-mail:
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Leitner GC, Vogelsang H. Pharmacological- and non-pharmacological therapeutic approaches in inflammatory bowel disease in adults. World J Gastrointest Pharmacol Ther 2016; 7:5-20. [PMID: 26855808 PMCID: PMC4734954 DOI: 10.4292/wjgpt.v7.i1.5] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 12/14/2015] [Accepted: 01/08/2016] [Indexed: 02/06/2023] Open
Abstract
Inflammatory bowel diseases (IBDs) are a group of chronic inflammatory conditions mainly of the colon and small intestine. Crohn's disease (CD) and ulcerative colitis (UC) are the most frequent types of IBD. IBD is a complex disease which arises as a result of the interaction of environmental, genetic and immunological factors. It is increasingly thought that alterations of immunological reactions of the patients to their own enterable bacteria (microfilm) may contribute to inflammation. It is characterized by mucosal and sub mucosal inflammation, perpetuated by infiltration of activated leukocytes. CD may affect the whole gastrointestinal tract while UC only attacks the large intestine. The therapeutic goal is to achieve a steroid-free long lasting remission in both entities. UC has the possibility to be cured by a total colectomy, while CD never can be cured by any operation. A lifelong intake of drugs is mostly necessary and essential. Medical treatment of IBD has to be individualized to each patient and usually starts with anti-inflammatory drugs. The choice what kind of drugs and what route administered (oral, rectal, intravenous) depends on factors including the type, the localization, and severity of the patient's disease. IBD may require immune-suppression to control symptoms such as prednisolone, thiopurines, calcineurin or sometimes folic acid inhibitors or biologics like TNF-α inhibitors or anti-integrin antibodies. For both types of disease (CD, UC) the same drugs are available but they differ in their preference in efficacy between CD and UC as 5-aminosalicylic acid for UC or budesonide for ileocecal CD. As therapeutic alternative the main mediators of the disease, namely the activated pro-inflammatory cytokine producing leukocytes can be selectively removed via two apheresis systems (Adacolumn and Cellsorba) in steroid-refractory or dependent cases. Extracorporeal photopheresis results in an increase of regulatory B cells, regulatory CD8(+) T cells and T-regs Type 1. Both types of apheresis were able to induce clinical remission and mucosal healing accompanied by tapering of steroids.
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Abstract
The prevalence of extraintestinal manifestations in inflammatory bowel diseases varies from 6% to 46%. The aetiology of extraintestinal manifestations remains unclear. There are theories based on an immunological response influenced by genetic factors. Extraintestinal manifestations can involve almost every organ system. They may originate from the same pathophysiological mechanism of intestinal disease, or as secondary complications of inflammatory bowel diseases, or autoimmune diseases susceptibility. The most frequently involved organs are the joints, skin, eyes, liver and biliary tract. Renal involvement has been considered as an extraintestinal manifestation and has been described in both Crohn's disease and ulcerative colitis. The most frequent renal involvements in patients with inflammatory bowel disease are nephrolithiasis, tubulointerstitial nephritis, glomerulonephritis and amyloidosis. The aim of this review is to evaluate and report the most important data in the literature on renal involvement in patients with inflammatory bowel disease. Bibliographical searches were performed of the MEDLINE electronic database from January 1998 to January 2015 with the following key words (all fields): (inflammatory bowel disease OR Crohn's disease OR ulcerative colitis) AND (kidney OR renal OR nephrotoxicity OR renal function OR kidney disease OR renal disease OR glomerulonephritis OR interstitial nephritis OR amyloidosis OR kidney failure OR renal failure) AND (5-aminosalicylic acid OR aminosalicylate OR mesalazine OR TNF-α inhibitors OR cyclosporine OR azathioprine OR drugs OR pediatric).
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Affiliation(s)
- Domenico Corica
- Department of Pediatrics, University of Messina, Messina, Italy
| | - Claudio Romano
- Department of Pediatrics, University of Messina, Messina, Italy
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Abstract
Ulcerative colitis (UC) and Crohn's disease (CD) are chronic inflammatory disorders, which require long term treatment to achieve remission and to prevent relapses and cancer. While current therapies are effective in most cases, they can have rare but serious side effects and are often associated with high costs. On the other hand, early discontinuation of an effective treatment may lead to a quick relapse and to complications at the restart of therapy. Therefore it is essential to determine the optimal duration of maintenance therapy, but clear guidelines are missing. The most important questions when deciding whether to continue or withdraw therapy in quiescent UC and CD patients are the efficacy of the continuous treatment to maintain remission in the long term, the frequency and severity of side effects, and the chance of relapse after discontinuation of therapy. This review summarizes the current knowledge on these topics with respect to 5-aminosalicylates, thiopurines, methotrexate, and biological therapies and collects information regarding when and in which specific patient groups, in the absence of risk factors, can withdrawal of therapy be considered without a high risk of relapse. Additionally, the particular aspect of colorectal cancer prevention by current therapies will also be discussed.
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Brouwers KJG, Vis R, Tupker RA. Itraconazole as a continuous treatment for atopic dermatitis? A case report. J Eur Acad Dermatol Venereol 2015; 30:873-4. [PMID: 25702780 DOI: 10.1111/jdv.13040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- K J G Brouwers
- Department of Dermatology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - R Vis
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - R A Tupker
- Department of Dermatology, St. Antonius Hospital, Nieuwegein, The Netherlands
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Hou XF, Pan H, Xu LH, Zha QB, He XH, Ouyang DY. Piperine Suppresses the Expression of CXCL8 in Lipopolysaccharide-Activated SW480 and HT-29 Cells via Downregulating the Mitogen-Activated Protein Kinase Pathways. Inflammation 2014; 38:1093-102. [DOI: 10.1007/s10753-014-0075-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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