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Dhaliwal J, Tertigas D, Carman N, Lawrence S, Debruyn JC, Wine E, Church PC, Huynh HQ, Rashid M, El-Matary W, Deslandres C, Critch J, Ricciuto A, Carroll MW, Benchimol EI, Muise A, Jacobson K, Otley AR, Vallance B, Mack DR, Walters TD, Surette MG, Griffiths AM. Outcomes Following Acute Severe Colitis at Initial Presentation: A Multi-centre, Prospective, Paediatric Cohort Study. J Crohns Colitis 2024; 18:233-245. [PMID: 37602969 PMCID: PMC10896636 DOI: 10.1093/ecco-jcc/jjad143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Indexed: 08/22/2023]
Abstract
AIM To assess contemporary outcomes in children with acute severe ulcerative colitis [ASUC] at initial presentation. METHODS Between April 2014 and January 2019, children aged <17 years, with new onset ASUC (Paediatric Ulcerative Colitis Activity Index [PUCAI ≥65) were prospectively followed in a Canadian inception cohort study. 16S rRNA amplicon sequencing captured microbial composition of baseline faecal samples. Primary endpoint was corticosteroid-free clinical remission with intact colon at 1 year [PUCAI <10, no steroids ≥4 weeks]. RESULTS Of 379 children with new onset UC/IBD-unclassified, 105 [28%] presented with ASUC (42% male; median [interquartile range; [IQR]) age 14 [11-16] years; extensive colitis in all). Compared with mild UC, gut microbiome of ASUC patients had lower α-diversity, decreased beneficial anaerobes, and increased aerobes; 54 [51%] children were steroid-refractory and given infliximab [87% intensified regimen]. Corticosteroid-free remission at 1 year was achieved by 62 [61%] ASUC cohort (by 34 [63%] steroid-refractory patients, all on biologics; by 28 [55%] steroid responders,13 [25%] on 5- aminosalicylic acid [5-ASA], 5 [10%] on thiopurines, 10 [20%] on biologics). By 1 year, 78 [74%] escalated to infliximab including 24 [47%] steroid-responders failed by 5-ASA and/or thiopurines. In multivariable analysis, clinical predictors for commencing infliximab included hypoalbuminaemia, greater PUCAI, higher age, and male sex. Over 18 months, repeat corticosteroid course[s] and repeat hospitalisation were less likely among steroid-refractory versus -responsive but -dependent patients (adjusted odds ratio [aOR] 0.71 [95% CI 0.57-0.89] and 0.54 [95% CI 0.45-0.66], respectively). CONCLUSION The majority of children presenting with ASUC escalate therapy to biologics. Predictors of need for advanced therapy may guide selection of optimal maintenance therapy.
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Affiliation(s)
- Jasbir Dhaliwal
- SickKids IBD Centre, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Child Health and Evaluative Sciences, SickKids Research Institute, Hospital for Sick Children, Toronto, ON, Canada
- Cincinnati Children’s Hospital Medical Center, Division of Gastroenterology, Hepatology and Nutrition, Cincinnati, USA
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| | - Dominique Tertigas
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, Canada
| | - Nicholas Carman
- SickKids IBD Centre, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Sally Lawrence
- B.C. Children’s Hospital, Division of Gastroenterology, Hepatology and Nutrition, Vancouver, BC, Canada
| | - Jennifer C Debruyn
- Alberta Children’s Hospital, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Calgary, Calgary, AB, Canada
| | - Eytan Wine
- Stollery Children’s Hospital, Division of Gastroenterology, Hepatology and Nutrition, Edmonton, AB, Canada
| | - Peter C Church
- SickKids IBD Centre, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Hien Q Huynh
- Stollery Children’s Hospital, Division of Gastroenterology, Hepatology and Nutrition, Edmonton, AB, Canada
| | - Mohsin Rashid
- IWK Health Centre, University of Dalhousie, Division of Gastroenterology, Hepatology and Nutrition, Halifax, NS, Canada
| | - Wael El-Matary
- Winnipeg Children’s Hospital, Department of Paediatrics, University of Manitoba, Winnipeg, MN, Canada
| | - Colette Deslandres
- CHU Sainte-Justine, Department of Paediatrics, University of Montreal, Montreal, QC, Canada
| | - Jeffrey Critch
- Janeway Children’s Health and Rehabilitation Centre, Memorial University, St. John’s, NFLD, Canada
| | - Amanda Ricciuto
- SickKids IBD Centre, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Child Health and Evaluative Sciences, SickKids Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Matthew W Carroll
- Stollery Children’s Hospital, Division of Gastroenterology, Hepatology and Nutrition, Edmonton, AB, Canada
| | - Eric I Benchimol
- SickKids IBD Centre, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Child Health and Evaluative Sciences, SickKids Research Institute, Hospital for Sick Children, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Aleixo Muise
- SickKids IBD Centre, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Kevan Jacobson
- B.C. Children’s Hospital, Division of Gastroenterology, Hepatology and Nutrition, Vancouver, BC, Canada
| | - Anthony R Otley
- IWK Health Centre, University of Dalhousie, Division of Gastroenterology, Hepatology and Nutrition, Halifax, NS, Canada
| | - Bruce Vallance
- B.C. Children’s Hospital, Division of Gastroenterology, Hepatology and Nutrition, Vancouver, BC, Canada
| | - David R Mack
- Children’s Hospital of Eastern Ontario IBD Centre, Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | - Thomas D Walters
- SickKids IBD Centre, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Michael G Surette
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Anne M Griffiths
- SickKids IBD Centre, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Child Health and Evaluative Sciences, SickKids Research Institute, Hospital for Sick Children, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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Abstract
Acute severe ulcerative colitis (ASUC) is one of life-threatening complications that occur in one-fifth of ulcerative colitis (UC) patients with significant morbidity and an estimated mortality rate up to 1%. There are no validated clinical scoring systems for ASUC. Intravenous corticosteroids remain the cornerstone for the management of ASUC patients However, one-third of patients are steroid refractory and require colectomy in the pre-biologic era or salvage therapy in the post-biologic era. The currently available predictors of non-response to steroids and salvages therapy are sub-optimal. Furthermore, there is a need for the development of clear outcome measures for ASUC patients. Although infliximab and cyclosporin are both effective as salvage therapy, they still carry a rate of treatment failure. Hence, there is an unmet need to explore alternative therapeutic options before colectomy particularly in prior infliximab-exposed patients. This may include the introduction of small molecules with rapid onset of action as a salvage or sequential therapy and the use of slow-onset other biological therapy after "bridging" with cyclosporine. In this article, we explore the current best evidence-based practice and detail the gaps in knowledge in the management of ASUC.
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Affiliation(s)
| | - Emma Whitehead
- IBD Unit, Hull University Teaching Hospitals, Hull, HU3 2JZ, UK
| | - Shaji Sebastian
- IBD Unit, Hull University Teaching Hospitals, Hull, HU3 2JZ, UK.
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Chen Y, Li X, Sun R, Yang F, Tian W, Huang Q. Screening and experimental validation of diagnostic gene in ulcerative colitis with anti-TNF-α therapy. IUBMB Life 2024. [PMID: 38269750 DOI: 10.1002/iub.2807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 12/06/2023] [Indexed: 01/26/2024]
Abstract
In clinical practice, the diagnosis of ulcerative colitis (UC) mainly relies on a comprehensive analysis of a series of signs and symptoms of patients. The current biomarkers for diagnosis of UC and prognostic prediction of anti-TNF-α therapy are inaccurate. The present study aimed to perform an integrative analysis of gene expression profiles in patients with UC. A total of seven datasets from the GEO database that met our strict inclusion criteria were included. After identifying differentially expressed genes (DEGs) between UC patients and healthy individuals, the diagnostic and prognostic utility of the DEGs were then analyzed via least absolute shrinkage and selection operator and support-vector machine recursive feature elimination. Subgroup analyses of the treated and untreated groups, as well as the treatment-response group and non-response group, were also performed. Furthermore, the relationship between the expressions of UC-related genes and infiltration of immune cells in the course of treatment was also investigated. Immunohistochemical (IHC) assay was used to verify the gene expression in inflamed UC tissues. When considering all the applied methods, DUOX2, PI3, S100P, MMP7, and S100A8 had priority to be defined as the characteristic genes among DEGs. The area under curve (AUC) of the five genes, which were all consistently over-expressed, based on an external validation dataset, were all above 0.94 for UC diagnosis. Four of the five genes (DUOX2, PI3, MMP7, and S100A8) were down-regulated between treatment-responsive and nonresponsive patients. A significant difference was also observed concerning the infiltration of immune cells, including macrophage and neutrophil, between the two groups (treatment responsive and nonresponsive). The changes in the expression of DUOX2 and MMP7 based on the IHC assay were highly consistent with the results obtained in the current study. This confirmed the mild to moderate diagnostic and predictive value of DUOX2 and MMP7 in patients with UC. The conducted analyses showed that the expression profile of the five identified biomarkers accurately detects UC, whereas four of the five genes evidently predicted the response to anti-TNF-α therapy.
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Affiliation(s)
- Yuan Chen
- Research Institute of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, People's Republic of China
| | - Xinfang Li
- Research Institute of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, People's Republic of China
| | - Ran Sun
- Research Institute of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, People's Republic of China
| | - Fan Yang
- Research Institute of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, People's Republic of China
| | - Weiliang Tian
- Research Institute of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, People's Republic of China
| | - Qian Huang
- Research Institute of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, People's Republic of China
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González-Lama Y, Ricart E, Carpio D, Bastida G, Ceballos D, Ginard D, Marin-Jimenez I, Menchen L, Muñoz F. Controversies in the management of anti-TNF therapy in patients with Crohn's disease: a Delphi consensus. BMJ Open Gastroenterol 2024; 11:e001246. [PMID: 38267072 PMCID: PMC10870792 DOI: 10.1136/bmjgast-2023-001246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 10/24/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Despite research, there are still controversial areas in the management of Crohn's disease (CD). OBJECTIVE To establish practical recommendations on using anti-tumour necrosis factor (TNF) drugs in patients with moderate-to-severe CD. METHODS Clinical controversies in the management of CD using anti-TNF therapies were identified. A comprehensive literature review was performed, and a national survey was launched to examine current clinical practices when using anti-TNF therapies. Their results were discussed by expert gastroenterologists within a nominal group meeting, and a set of statements was proposed and tested in a Delphi process. RESULTS Qualitative study. The survey and Delphi process were sent to 244 CD-treating physicians (response rate: 58%). A total of 14 statements were generated. All but two achieved agreement. These statements cover: (1) use of first-line non-anti-TNF biological therapy; (2) role of HLA-DQA1*05 in daily practice; (3) attitudes in primary non-response and loss of response to anti-TNF therapy due to immunogenicity; (4) use of ustekinumab or vedolizumab if a change in action mechanism is warranted; (5) anti-TNF drug level monitoring; (6) combined therapy with an immunomodulator. CONCLUSION This document sought to pull together the best evidence, experts' opinions, and treating physicians' attitudes when using anti-TNF therapies in patients with CD.
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Affiliation(s)
- Yago González-Lama
- Gastroenterology Department, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | - Elena Ricart
- Gastroenterology Department, CIBEREHD, Madrid, Spain
| | - Daniel Carpio
- Gastroenterology Department, Complexo Hospitalario Universitario de Pontevedra, Pontevedra, Spain
| | | | - Daniel Ceballos
- Gastroenterology Department, Hospital Universitario Doctor Negrin, Las Palmas de Gran Canaria, Spain
| | - Daniel Ginard
- Gastroenterology Department, Hospital Universitario Son Espases, Palma, Spain
| | | | - Luis Menchen
- Gastroenterology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Fernando Muñoz
- Gastroenterology Department, Hospital Universitario de Salamanca, Salamanca, Spain
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Anti-TNF. Gastroenterol Hepatol (N Y) 2024; 20:3-4. [PMID: 38444831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
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Li A, Coote M, Thin L. Prevalence and risk factors for early medical and surgical complications following an admission for acute severe ulcerative colitis. Therap Adv Gastroenterol 2023; 16:17562848231215148. [PMID: 38059014 PMCID: PMC10697038 DOI: 10.1177/17562848231215148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 11/02/2023] [Indexed: 12/08/2023] Open
Abstract
Background Risk factors for colectomy following an episode of acute severe ulcerative colitis (ASUC) have been well studied, but data examining the early complications following an episode is limited. Objectives We aimed to evaluate the prevalence and risk factors for medical and surgical complications within 90 days of an ASUC admission and determine if a high-intensity induction infliximab dose is associated with these complications. Design Retrospective analysis. Methods We conducted a retrospective study of ASUC admissions between January 2015 and July 2021 at a tertiary hospital. The primary outcome was the prevalence of total, medical and surgical complications within 90 days following an ASUC admission. Multivariate linear regression analysis assessed for factors associated with the prevalence of complications. Results A total of 150 patients had 186 hospital admissions for ASUC. In total, 101/186 (54.3%) admissions required rescue medical therapy. Standard infliximab induction occurred in 65/100 admissions, accelerated infliximab induction in 35/100 and cyclosporine in 1/100 of admissions. In total, 117 complications, including 74/117 (63.2%) medical and 43/117 (36.8%) surgical complications, arose. Low serum albumin was independently associated with a higher incidence of total [β = -0.08 (95% confidence interval (CI): -0.15, -0.01), p = 0.03] and surgical complications [β = -0.1 (95% CI: -0.18, -0.001), p = 0.047], while an increased age was associated with increased incidence of surgical complications [β = 0.06 (95% CI: 0.01, 0.12), p = 0.02]. A higher Charlson score was associated with increased medical complications [β = 0.12 (95% CI: 0.01, 0.24), p = 0.03]. Infliximab induction dose intensity was not associated with an increased incidence of any complications. Conclusion Early complications following an ASUC admission is prevalent although the majority are not serious. Risk factors associated with complications include low serum albumin, older age and a higher comorbidity score. Induction infliximab dose intensity, however, is not a risk factor.
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Affiliation(s)
- Angel Li
- Department of Gastroenterology, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Matthew Coote
- Department of Gastroenterology, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Lena Thin
- Department of Internal Medicine, University of Western Australia, Medical School, 11 Robin Warren Drive, Murdoch, WA 6150, Australia
- Department of Gastroenterology, Fiona Stanley Hospital, Murdoch, WA, Australia
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Clark N, MacIsaac M, Little R, Vogrin S, Harrison M, Tiang T, Keck J, Johnston M, Cunningham G, Wright E, Connell W. Have changing practices in salvage medical options affected colectomy rates in acute severe ulcerative colitis? Intern Med J 2023; 53:2231-2239. [PMID: 36916208 DOI: 10.1111/imj.16074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 03/07/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND In 2014, infliximab (IFX) was listed on the Australian Pharmaceutical Benefits Scheme for acute severe ulcerative colitis (ASUC) and is now the preferred option for medical salvage, superseding cyclosporin A (CsA). Optimal dosing schedules for IFX remain unknown. AIM The authors aim to evaluate the effect of changing from predominantly CsA to almost exclusively IFX for the treatment of steroid-refractory ASUC on colectomy rates. METHODS A retrospective review was performed of patients admitted with ASUC between 2012 and 2020. Patients were categorised into two groups according to year of presentation - either 'historical treatment' cohort (2012-2014), when CsA was primarily used, or 'contemporary treatment' cohort (2014-2020), when IFX was mostly prescribed, in either standard or intensive doses. RESULTS One hundred thirty-nine patients were included; 37 in the historical treatment cohort and 102 in the contemporary treatment cohort. In the historical treatment cohort, 12 of 37 received salvage therapy and eight (67%) received CsA. In the contemporary treatment cohort, 49 of 102 patients received salvage therapy, 40 (82%) with IFX, of whom 22 (53%) received intensified doses. Colectomy rates were similar at 30 days, 6 months and 12 months between historical and contemporary treatment cohorts (14% vs 12% [P = 0.77], 19% vs 18% [P > 0.99],and 22% vs 18% [P = 0.63], respectively). Difference in 12-month colectomy rates between standard versus intensive IFX did not meet statistical significance (three of 21 [14%] vs nine of 22 [41%]. respectively; P = 0.09). CONCLUSION There was no difference in 30-day, 6-month or 12-month colectomy rates between the historical treatment and contemporary treatment cohorts. The use of IFX, rather than CsA, even at intensified dosing, does not appear to reduce the colectomy rate observed in our patients.
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Affiliation(s)
- Nicholas Clark
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Michael MacIsaac
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Robert Little
- Department of Gastroenterology, The Alfred Hospital, Melbourne, Australia
- Monash University, Monash Health, Victoria, Melbourne, Australia
| | - Sara Vogrin
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Victoria, Australia
- The University of Melbourne, Melbourne, Victoria, Australia
| | - Maria Harrison
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Thomas Tiang
- Department of Colorectal Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - James Keck
- Department of Colorectal Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Michael Johnston
- Department of Colorectal Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Georgina Cunningham
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Emily Wright
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - William Connell
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Victoria, Australia
- The University of Melbourne, Melbourne, Victoria, Australia
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Mouhtar El Hálabi S, Valdés Delgado T, Maldonado Pérez B, Belvis Jiménez M, Argüelles Arias F. Severe outbreak of ulcerative colitis and cerebral neoplasia. Difficult management in COVID time. Rev Esp Enferm Dig 2023; 115:657. [PMID: 36926936 DOI: 10.17235/reed.2023.9527/2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
A 61-year-old male diabetic patient, diagnosed with ulcerative colitis (UC) 30 years ago, currently under treatment with mesalazine is presented. He was admitted to the emergency department due to a severe outbreak of UC, with 15 depositions daily, rectal bleeding and poor general condition. A brain CT-scan was carried out in the emergency department due to a sudden self-limited aphasia. A left frontal lesion of 45x38 mms with a prominent perilesional edema and with a displacement of the midline was reported. This was believed to be a meningioma (figure 1A). Urgent neurosurgery was not performed, prioritizing the severe flare-up UC. Based on this, full-dose metilprednisolone was administered.
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Kayal M, Meringer H, Martin L, Colombel JF. Systematic review: Scores used to predict outcomes in acute severe ulcerative colitis. Aliment Pharmacol Ther 2023; 58:974-983. [PMID: 37817604 DOI: 10.1111/apt.17731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/14/2023] [Accepted: 09/14/2023] [Indexed: 10/12/2023]
Abstract
Predictive scores for ASUC outcomes according to time of application.
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Affiliation(s)
- Maia Kayal
- Henry D. Janowitz Division of Gastroenterology, Susan and Leonard Feinstein Inflammatory Bowel Disease Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Hadar Meringer
- Henry D. Janowitz Division of Gastroenterology, Susan and Leonard Feinstein Inflammatory Bowel Disease Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lily Martin
- Library Education & Research Services, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jean Frederic Colombel
- Henry D. Janowitz Division of Gastroenterology, Susan and Leonard Feinstein Inflammatory Bowel Disease Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Antunes PB, Gonçalves B, Arroja B, Gonçalves R, Leal T. Infliximab Induction Strategies in Corticosteroid-Refractory Acute Severe Ulcerative Colitis: A Case Series and Literature Review. GE Port J Gastroenterol 2023; 30:390-397. [PMID: 37868637 PMCID: PMC10586214 DOI: 10.1159/000526509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 07/04/2022] [Indexed: 10/24/2023]
Abstract
Acute severe ulcerative colitis (ASUC) is an emergent medical condition and particularly challenging to treat efficaciously. Infliximab is one of the medical salvage treatment options after corticosteroid refractoriness, but the best induction strategy is not yet defined. With this case series, the authors intend to describe three corticosteroid-refractory ASUC cases with different intensified/accelerated infliximab induction approaches and review the literature on this topic. The first case describes an 18-year-old girl with ASUC at disease onset with rapid progression to toxic megacolon, complicated also with anemia, hypoalbuminemia, and coagulopathy. After corticosteroid failure, both accelerated and intensified (10 mg/kg) infliximab regimen was completed within 11 days, with solid clinical response and colon imaging normalization. Second, we present a 26-year-old male with left-sided ulcerative colitis known for 2 years, under mesalazine, who developed a moderate flare and was started on infliximab after partial and inconsistent response to corticosteroids. During the induction period, he presented this time an ASUC episode, which motivated an early and intensified third dose with good clinical response. Finally, we describe the case of a 78-year-old man with ulcerative proctitis for 12 years presenting ASUC with proximal disease extension as well. After unsatisfactory response to corticosteroids, infliximab was initiated on an accelerated induction regimen, completed in 13 days, with the standard dose, achieving clinical remission. Accelerated or intensified infliximab induction plans are becoming current clinical practice in corticosteroid-refractory ASUC. Current guidelines refer to the possibility of this type of strategies, not determining the optimal regimen due to lack of solid evidence. Literature is mainly based on retrospective studies, not randomized, with heterogeneous groups according to disease severity, and the effect on colectomy rates, mainly on the long term, is not clear. Additional well-supported studies are needed on this subject in order to seek a more widely uniform approach.
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Calméjane L, Laharie D, Kirchgesner J, Uzzan M. Review article: Updated management of acute severe ulcerative colitis: From steroids to novel medical strategies. United European Gastroenterol J 2023; 11:722-732. [PMID: 37475143 PMCID: PMC10576604 DOI: 10.1002/ueg2.12442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 06/15/2023] [Indexed: 07/22/2023] Open
Abstract
Acute severe ulcerative colitis (ASUC) occurs in up to 25% of patients with ulcerative colitis (UC). Therapeutic approaches have evolved during the past years with the increasing bio exposure of admitted patients and the extension of the number of approved drugs for UC. In this review, we aimed to summarize the latest evidence in short-term and long-term medical strategies for ASUC. In addition to general principles such as venous thromboembolism prophylaxis, screening for triggering and worsening factors and close monitoring, first-line therapy for ASUC remains intravenous corticosteroids. In naive patients, the optimum maintenance strategy for steroid-responding patients does not necessarily include biologics. Second-line therapy includes infliximab or calcineurin inhibitors (CNIs) with similar short- and long-term colectomy rates. Despite its pathophysiological relevance, there is insufficient evidence to promote intensified induction with infliximab. Prior treatment exposure is a cornerstone for guiding therapeutic choice of short- and long-term therapies in the context of ASUC: in anti-TNF exposed patients, CNIs may be favored as a bridge therapy to vedolizumab or ustekinumab. Third-line salvage therapy could be a therapeutic option in selected patients referred to expert centers. Additionally, evidence is accumulating regarding the use of tofacitinib in ASUC.
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Affiliation(s)
| | - David Laharie
- CHU de BordeauxHôpital Haut‐LévêqueService d’Hépato‐gastroentérologie et Oncologie Digestive – Université de BordeauxBordeauxFrance
| | - Julien Kirchgesner
- Gastroenterology DepartmentSorbonne UniversitéSaint‐Antoine HospitalParisFrance
| | - Mathieu Uzzan
- Gastroenterology DepartmentParis Est Créteil University UPECHenri Mondor HospitalFédération Hospitalo‐Universitaire TRUE InnovaTive theRapy for ImmUne DisordErsCréteilFrance
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Li Wai Suen CFD, Seah D, Choy MC, De Cruz P. Factors Associated With Response to Rescue Therapy in Acute Severe Ulcerative Colitis. Inflamm Bowel Dis 2023:izad183. [PMID: 37725044 DOI: 10.1093/ibd/izad183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Acute severe ulcerative colitis (ASUC) is a medical emergency for which colectomy is required in patients who do not respond to rescue therapy. While previous studies have predominantly focused on predicting outcome to first-line corticosteroid therapy, there is a need to understand the factors associated with response to rescue therapies in order to improve clinical outcomes. We reviewed the evidence regarding factors associated with response to rescue therapy in adults with ASUC and identified future directions for research. METHODS A systematic search of the literature was conducted, and 2 reviewers independently assessed studies for inclusion. RESULTS Of 3509 records screened, 101 completed studies were eligible for inclusion. We identified 42 clinical, hematological, biochemical, endoscopic, or pharmacological factors associated with response to rescue therapy. Older age (≥50 years), thiopurine experience, and cytomegalovirus or Clostridioides difficile infection were associated with a higher risk of nonresponse to rescue therapy. Biochemical factors associated with poorer response included an elevated C-reactive protein (CRP) ≥30mg/L on admission, hypoalbuminemia and an elevated ratio of CRP to albumin. Severe endoscopic findings, including a Mayo endoscopic score of 3 or Ulcerative Colitis Endoscopic Index of Severity ≥5, portended poorer outcomes. The role of fecal calprotectin and therapeutic value of measuring infliximab drug levels in ASUC remain to be defined. CONCLUSIONS Response to rescue therapy can be predicted by several specific factors, which would aid clinical decision-making. Existing and emerging factors should be integrated within predictive and prognostic models to help improve clinical outcomes.
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Affiliation(s)
- Christopher F D Li Wai Suen
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia
- Department of Medicine, Austin Academic Centre, University of Melbourne, Melbourne, VIC, Australia
| | - Dean Seah
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia
| | - Matthew C Choy
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia
- Department of Medicine, Austin Academic Centre, University of Melbourne, Melbourne, VIC, Australia
| | - Peter De Cruz
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia
- Department of Medicine, Austin Academic Centre, University of Melbourne, Melbourne, VIC, Australia
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Zimmerman LA, Spaan J, Weinbren N, Manokaran K, Ajithkumar A, Bogursky A, Liu E, Lillehei C, Weil BR, Zalieckas JM, Bousvaros A, Rufo PA. Efficacy and Safety of Tacrolimus or Infliximab Therapy in Children and Young Adults With Acute Severe Colitis. J Pediatr Gastroenterol Nutr 2023; 77:222-227. [PMID: 37477885 DOI: 10.1097/mpg.0000000000003824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
INTRODUCTION One-third of children and young adults admitted for management of acute severe colitis (ASC) fail intravenous corticosteroids. Infliximab (IFX) or tacrolimus (TAC) is often used to prevent urgent colectomy in these patients. However, no prior studies have reviewed the outcome of pediatric patients with ASC who were treated with either IFX or TAC. METHODS We retrospectively identified 170 pediatric patients with ASC admitted to our institution who did not respond to intravenous corticosteroids and were subsequently treated with either IFX or TAC. We compared 6-month colectomy rates, time to colectomy, improvement in disease activity indices, and adverse effects. RESULTS The mean age of patients in the IFX (n = 84) and TAC (n = 86) groups were 14 and 13.8 years, respectively. The median study follow-up time was 23 months. The rate of colectomy 6 months from rescue therapy was similar whether patients received IFX or TAC (22.6% vs 26.7%, respectively, P = 0.53). The mean decline in Pediatric Ulcerative Colitis Activity Index scores from admission to discharge in those treated with IFX (31.9) or TAC (29.8) was similar (P = 0.63). Three patients treated with IFX experienced infusion reactions. Six patients treated with TAC experienced changes in renal function or electrolytes, and 4 patients reported neurologic symptoms. CONCLUSIONS There were no significant differences in the likelihood of colectomy 6 months after initiating IFX or TAC rescue therapy. Efficacy of both agents was comparable. The types of adverse effects differed by therapy. These data support the use of either TAC or IFX in children with ASC refractory to intravenous corticosteroids.
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Affiliation(s)
- Lori A Zimmerman
- From the Division of Gastroenterology and Nutrition, IBD Center, Boston Children's Hospital, Boston, MA
| | - Jonathan Spaan
- From the Division of Gastroenterology and Nutrition, IBD Center, Boston Children's Hospital, Boston, MA
| | - Nathan Weinbren
- From the Division of Gastroenterology and Nutrition, IBD Center, Boston Children's Hospital, Boston, MA
| | - Krishanth Manokaran
- From the Division of Gastroenterology and Nutrition, IBD Center, Boston Children's Hospital, Boston, MA
| | - Aravindh Ajithkumar
- From the Division of Gastroenterology and Nutrition, IBD Center, Boston Children's Hospital, Boston, MA
| | - Anna Bogursky
- From the Division of Gastroenterology and Nutrition, IBD Center, Boston Children's Hospital, Boston, MA
| | - Enju Liu
- From the Division of Gastroenterology and Nutrition, IBD Center, Boston Children's Hospital, Boston, MA
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA
| | - Craig Lillehei
- the Department of Surgery, IBD Center, Boston Children's Hospital, Boston, MA
| | - Brent R Weil
- the Department of Surgery, IBD Center, Boston Children's Hospital, Boston, MA
| | - Jill M Zalieckas
- the Department of Surgery, IBD Center, Boston Children's Hospital, Boston, MA
| | - Athos Bousvaros
- From the Division of Gastroenterology and Nutrition, IBD Center, Boston Children's Hospital, Boston, MA
| | - Paul A Rufo
- From the Division of Gastroenterology and Nutrition, IBD Center, Boston Children's Hospital, Boston, MA
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14
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Berinstein JA, Aintabi D, Higgins PDR. In-hospital management of inflammatory bowel disease. Curr Opin Gastroenterol 2023; 39:274-286. [PMID: 37265192 DOI: 10.1097/mog.0000000000000953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
PURPOSE OF REVIEW The management of hospitalized patients with inflammatory bowel disease (IBD) is complex. Despite considerable therapeutic advancements in outpatient ulcerative colitis and Crohn's disease management, the in-hospital management continues to lag with suboptimal outcomes. The purpose of this review is to provide a brief overview of our approach to managing patients hospitalized with acute severe ulcerative colitis (ASUC) and Crohn's disease-related complications, followed by a summary of emerging evidence for new management approaches. RECENT FINDINGS ASUC has seen the emergence of well validated prognostic models for colectomy as well as the development of novel treatment strategies such as accelerated infliximab dosing, Janus kinase inhibitor therapy, and sequential therapy, yet the rate of colectomy for steroid-refractory ASUC has not meaningfully improved. Crohn's disease has seen the development of better diagnostic tools, early Crohn's disease-related complication stratification and identification, as well as better surgical techniques, yet the rates of hospitalization and development of Crohn's disease-related complications remain high. SUMMARY Significant progress has been made in the in-hospital IBD management; however, both the management of ASUC and hospitalized Crohn's disease remain a challenge with suboptimal outcomes. Critical knowledge gaps still exist, and dedicated studies in hospitalized patients with IBD are needed to address them.
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Affiliation(s)
- Jeffrey A Berinstein
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, Ann Arbor
| | - Daniel Aintabi
- Department of Medicine, Trinity Health Ann Arbor Hospital, Ypsilanti, Michigan, USA
| | - Peter D R Higgins
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, Ann Arbor
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15
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Blais A, Lan A, Blachier F, Benamouzig R, Jouet P, Couvineau A. Efficiency of Orexin-A for Inflammatory Flare and Mucosal Healing in Experimental Colitis: Comparison with the Anti-TNF Alpha Infliximab. Int J Mol Sci 2023; 24:ijms24119554. [PMID: 37298505 DOI: 10.3390/ijms24119554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 05/25/2023] [Accepted: 05/29/2023] [Indexed: 06/12/2023] Open
Abstract
Inflammatory bowel diseases are chronic inflammation of the intestinal mucosa characterized by relapsing-remitting cycle periods of variable duration. Infliximab (IFX) was the first monoclonal antibody used for the treatment of Crohn's disease and ulcerative colitis (UC). High variability between treated patients and loss of IFX efficiency over time support the further development of drug therapy. An innovative approach has been suggested based on the presence of orexin receptor (OX1R) in the inflamed human epithelium of UC patients. In that context, the aim of this study was to compare, in a mouse model of chemically induced colitis, the efficacy of IFX compared to the hypothalamic peptide orexin-A (OxA). C57BL/6 mice received 3.5% dextran sodium sulfate (DSS) in drinking water for 5 days. Since the inflammatory flare was maximal at day 7, IFX or OxA was administered based on a curative perspective at that time for 4 days using intraperitoneal injection. Treatment with OxA promoted mucosal healing and decreased colonic myeloperoxidase activity, circulating concentrations of lipopolysaccharide-binding protein, IL-6 and tumor necrosis factor alpha (TNFα) and decreased expression of genes encoding cytokines in colonic tissues with better efficacy than IFX allowing for more rapid re-epithelization. This study demonstrates the comparable anti-inflammatory properties of OxA and IFX and shows that OxA is efficient in promoting mucosal healing, suggesting that OxA treatment is a promising new biotherapy.
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Affiliation(s)
- Anne Blais
- UMR-PNCA, Université Paris-Saclay, AgroParisTech, INRAE, 91120 Palaiseau, France
| | - Annaïg Lan
- UMR-PNCA, Université Paris-Saclay, AgroParisTech, INRAE, 91120 Palaiseau, France
| | - François Blachier
- UMR-PNCA, Université Paris-Saclay, AgroParisTech, INRAE, 91120 Palaiseau, France
| | - Robert Benamouzig
- UMR-PNCA, Université Paris-Saclay, AgroParisTech, INRAE, 91120 Palaiseau, France
- Hôpital Avicenne, Assistance Publique-Hôpitaux de Paris, 93000 Bobigny, France
| | - Pauline Jouet
- Hôpital Avicenne, Assistance Publique-Hôpitaux de Paris, 93000 Bobigny, France
| | - Alain Couvineau
- INSERM UMR 1149/Centre de Recherche sur l'Inflammation (CRI), Faculté de Médecine X. Bichat, Université Paris Cité, 75018 Paris, France
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16
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Gordon BL, Battat R. Therapeutic Drug Monitoring of Infliximab in Acute Severe Ulcerative Colitis. J Clin Med 2023; 12:jcm12103378. [PMID: 37240484 DOI: 10.3390/jcm12103378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 05/01/2023] [Accepted: 05/05/2023] [Indexed: 05/28/2023] Open
Abstract
Therapeutic drug monitoring (TDM) is a useful strategy in ulcerative colitis (UC). Nearly a quarter of UC patients will experience acute severe UC (ASUC) in their lifetime, including 30% who will fail first-line corticosteroid therapy. Steroid-refractory ASUC patients require salvage therapy with infliximab, cyclosporine, or colectomy. Fewer data are available for the use of TDM of infliximab in ASUC. The pharmacokinetics of ASUC make TDM in this population more complex. High inflammatory burden is associated with increased infliximab clearance, which is associated with lower infliximab drug concentrations. Observational data support the association between increased serum infliximab concentrations, lower clearance, and favorable clinical and endoscopic outcomes, as well as decreased rates of colectomy. Data regarding the benefit of accelerated or intensified dosing strategies of infliximab-as well as target drug concentration thresholds-in ASUC patients remain more equivocal, though limited by their observational nature. Studies are underway to further evaluate optimal dosing and TDM targets in this population. This review examines the evidence for TDM in patients with ASUC, with a focus on infliximab.
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Affiliation(s)
- Benjamin L Gordon
- Division of Gastroenterology and Hepatology, New York-Presbyterian/Weill Cornell Medical Center, New York, NY 10065, USA
| | - Robert Battat
- Center for Clinical and Translational Research in Inflammatory Bowel Diseases, Centre Hospitalier de l'Université de Montréal, Montreal, QC H2X 0A9, Canada
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17
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Bui HH, Dang LM, Thi-Ngoc Vo D, Nguyen CD. Colonic Dilatation Complicating Acute Severe Ulcerative Colitis Managed Successfully with Accelerated Infliximab Dosing. Case Rep Gastroenterol 2023; 17:82-88. [PMID: 36760465 PMCID: PMC9906040 DOI: 10.1159/000529152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 01/09/2023] [Indexed: 02/10/2023] Open
Abstract
Lately, emerging data suggest an association between the development of inflammatory bowel disease and anti-interleukin-17 therapy. Megacolon is a life-threatening complication of acute severe ulcerative colitis (ASUC), but its treatment has not yet been established in current practice guidelines. We report a rare case of known psoriasis treated by secukinumab in a patient who presented with ASUC and colonic dilatation. Neither steroids nor standard infliximab regimen was effective. Finally, rescue therapy with accelerated infliximab strategy resulted in excellent recovery. In certain cases of steroid-refractory ASUC complicated by megacolon, accelerated infliximab regimen can be an alternative to surgery.
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Affiliation(s)
- Hoang Huu Bui
- Department of Gastroenterology, University Medical Center Ho Chi Minh City, Ho Chi Minh City, Vietnam,Department of Internal Medicine, University Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Luan Minh Dang
- Department of Gastroenterology, University Medical Center Ho Chi Minh City, Ho Chi Minh City, Vietnam,Department of Internal Medicine, University Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Diem Thi-Ngoc Vo
- Department of Pathology, University Medical Center Ho Chi Minh City, Ho Chi Minh City, Vietnam,Department of Pathology, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Chuong Dinh Nguyen
- Department of Gastroenterology, University Medical Center Ho Chi Minh City, Ho Chi Minh City, Vietnam
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18
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Nakase H. Acute Severe Ulcerative Colitis: Optimal Strategies for Drug Therapy. Gut Liver 2023; 17:49-57. [PMID: 36375793 PMCID: PMC9840911 DOI: 10.5009/gnl220017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 04/01/2022] [Accepted: 04/14/2022] [Indexed: 11/16/2022] Open
Abstract
Acute severe ulcerative colitis (ASUC) is a life-threatening medical emergency with considerable morbidity (30% to 40%). Patients with ASUC require hospitalization for prompt medical treatment, and colectomy is considered if medical therapy fails. Corticosteroids remain the primary initial therapy, although one-third of patients do not respond to treatment. Clinical data have indicated that cyclosporine, tacrolimus, and infliximab can be used to treat patients with ASUC who do not respond to intravenous corticosteroids. The effectiveness and safety of sequential therapy have recently been reported; however, the data are not convincing. Importantly, timely decision-making with rescue therapy or surgical treatment is critical to manage ASUC without compromising the health or safety of the patients. In addition, risk stratification and the use of predictive clinical parameters have improved the clinical outcome.of ASUC. Multidisciplinary teams that include inflammatory bowel disease experts, colorectal surgeons, and other medical staff contribute to the better management of patients with ASUC. In this review, we introduce current evidence and present a clinical approach to manage ASUC.
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Affiliation(s)
- Hiroshi Nakase
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan,Corresponding AuthorHiroshi Nakase, ORCIDhttps://orcid.org/0000-0003-2848-6586, E-mail
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19
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Na SY, Choi CH, Song EM, Bang KB, Park SH, Kim ES, Park JJ, Keum B, Lee CK, Lee BI, Ryoo SB, Koh SJ, Choi M, Kim JS. Korean clinical practice guidelines on biologics and small molecules for moderate-to-severe ulcerative colitis. Intest Res 2023; 21:61-87. [PMID: 35645321 PMCID: PMC9911265 DOI: 10.5217/ir.2022.00007] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 03/07/2022] [Indexed: 02/09/2023] Open
Abstract
Ulcerative colitis (UC), a relapsing-remitting chronic inflammatory bowel disease (IBD), has a variable natural course but potentially severe disease course. Since the development of anti-tumor necrosis factor (TNF) agents has changed the natural disease course of moderate-to-severe UC, therapeutic options for patients who failed conventional treatments are expanding rapidly. IBD clinical trials have demonstrated the potential efficacy and safety of novel biologics such as anti-integrin α4β7 and anti-interleukin-12/23 monoclonal antibodies and small molecules such as a Janus kinase inhibitor. Anti-TNF biosimilars also have been approved and are widely used in IBD patients. Wise drug choices should be made considering evidence-based efficacy and safety. However, the best position of these drugs remains several questions, with limited data from direct comparative trials. In addition, there are still concerns to be elucidated on the effect of therapeutic drug monitoring and combination therapy with immunomodulators. The appropriate treatment regimens in acute severe UC and the risk of perioperative use of biologics are unclear. As novel biologics and small molecules have been approved in Korea, we present the Korean guidelines for medical management of adult outpatients with moderate-to-severe UC and adult hospitalized patients with acute severe UC, focusing on biologics and small molecules.
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Affiliation(s)
- Soo-Young Na
- Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Chang Hwan Choi
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea,Correspondence to Chang Hwan Choi, Department of Internal Medicine, Chung-Ang University College of Medicine, 102 Heukseok-ro, Dongjak-gu, Seoul 06973, Korea. Tel: +82-2-6299-1418, Fax: +82-2-6299-2064, E-mail:
| | - Eun Mi Song
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Ki Bae Bang
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Sang Hyoung Park
- Department of Gastroenterology and Inflammatory Bowel Disease Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Soo Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jae Jun Park
- Department of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Bora Keum
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Chang Kyun Lee
- Department of Gastroenterology, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Bo-In Lee
- Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung-Bum Ryoo
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Seong-Joon Koh
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Miyoung Choi
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Joo Sung Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Herrera-deGuise C, Serra-Ruiz X, Lastiri E, Borruel N. JAK inhibitors: A new dawn for oral therapies in inflammatory bowel diseases. Front Med (Lausanne) 2023; 10:1089099. [PMID: 36936239 PMCID: PMC10017532 DOI: 10.3389/fmed.2023.1089099] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 02/09/2023] [Indexed: 03/06/2023] Open
Abstract
Inflammatory bowel disease (IBD) is a chronic immune-mediated condition of the gastrointestinal tract that requires chronic treatment and strict surveillance. Development of new monoclonal antibodies targeting one or a few single cytokines, including anti-tumor necrosis factor agents, anti-IL 12/23 inhibitors, and anti-α4β7 integrin inhibitors, have dominated the pharmacological armamentarium in IBD in the last 20 years. Still, many patients experience incomplete or loss of response or develop serious adverse events and drug discontinuation. Janus kinase (JAK) is key to modulating the signal transduction pathway of several proinflammatory cytokines directly involved in gastrointestinal inflammation and, thus, probably IBD pathogenesis. Targeting the JAK-STAT pathway offers excellent potential for the treatment of IBD. The European Medical Agency has approved three JAK inhibitors for treating adults with moderate to severe Ulcerative Colitis when other treatments, including biological agents, have failed or no longer work or if the patient cannot take them. Although there are currently no approved JAK inhibitors for Crohn's disease, upadacitinib and filgotinib have shown increased remission rates in these patients. Other JAK inhibitors, including gut-selective molecules, are currently being studied IBD. This review will discuss the JAK-STAT pathway, its implication in the pathogenesis of IBD, and the most recent evidence from clinical trials regarding the use of JAK inhibitors and their safety in IBD patients.
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21
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Constant BD, Baldassano R, Kirsch J, Mitchel EB, Stein R, Albenberg L. Tofacitinib Salvage Therapy for Children Hospitalized for Corticosteroid- and Biologic-Refractory Ulcerative Colitis. J Pediatr Gastroenterol Nutr 2022; 75:724-30. [PMID: 36122389 DOI: 10.1097/MPG.0000000000003616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES Colectomy rates following acute severe ulcerative colitis have plateaued around 20% despite intravenous corticosteroid and intensified anti-tumor necrosis factor (TNF) biologic dosing. Recent studies have shown tofacitinib to provide additional benefit in further decreasing colectomy rates among hospitalized adult patients with corticosteroid- and anti-TNF-nonresponsive ulcerative colitis. Pediatric data describing the effectiveness of tofacitinib for this indication does not yet exist. We aimed to describe the treatment courses and colectomy-free survival among pediatric patients treated with tofacitinib while hospitalized for refractory ulcerative colitis. METHODS We performed a retrospective single-center cohort study of consecutive hospitalized pediatric patients initiating tofacitinib for refractory ulcerative colitis from 2018 to 2021. The primary outcome was 90-day colectomy-free survival. Secondary outcomes included colectomy-free clinical remission, corticosteroid independence, colectomy-free tofacitinib drug-persistence, tofacitinib-related adverse events, and postoperative complications. Baseline characteristics and details of the timing and positioning of therapies utilized during hospitalization were described. Outcomes were described using counts, percentages, and Kaplan-Meier curves. RESULTS Eleven patients met inclusion criteria. All patients demonstrated nonresponse to both intravenous corticosteroids and anti-TNF therapy prior to tofacitinib initiation. Median hospitalization length was 22 days and mean maximum pediatric ulcerative colitis activity index during hospitalization was 68. Eight of 11 patients remained colectomy-free at 90 days following hospital admission and 6 remained colectomy-free over median 182-day follow-up, including 4 of whom remained on tofacitinib. CONCLUSIONS Tofacitinib may represent a new treatment option for hospitalized pediatric patients with corticosteroid- and anti-TNF-nonresponsive ulcerative colitis. Future research is essential in determining the optimal positioning of these therapies.
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22
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Ilvemark JFKF, Wilkens R, Thielsen P, Dige A, Boysen T, Brynskov J, Bjerrum JT, Seidelin JB. Early Intestinal Ultrasound Predicts Intravenous Corticosteroid Response in Hospitalised Patients With Severe Ulcerative Colitis. J Crohns Colitis 2022; 16:1725-1734. [PMID: 35695823 DOI: 10.1093/ecco-jcc/jjac083] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 05/19/2022] [Accepted: 06/10/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS Our aim was to determine if transabdominal intestinal ultrasound changes after 48 ± 24 h of intravenous corticosteroids can predict treatment outcomes in hospitalised patients with severe ulcerative colitis. METHODS We performed a blinded observational multicentre study. Ultrasound parameters were assessed before treatment initiation, after 48 ± 24 h, and 6 ± 1 days. Treatment response was determined within 7 days by two outcome measures: 1] partial Mayo score reduction; 2] no administration of rescue therapy. RESULTS Out of 69 recruited patients, 56 were included in the final analysis, with 37 responders. The colon segment with the highest baseline bowel wall thickness was analysed, being the sigmoid in all patients. There was no difference in baseline bowel wall thickness between responders and non-responders in the partial Mayo score outcome. At 48 ± 24 h, a significant difference between responders and non-responders was identified in both absolute bowel wall thickness [median 3.1 mm vs 4.9 mm; p <0.0001], absolute reduction [-1.9 mm vs -0.2 mm; p <0.001], and relative reduction [-35.9% vs -4.1%; p <0.0001]. A ≤20% reduction had a sensitivity of 84.2% (95% confidence interval [CI] 60.4, 96.6%) and a specificity of 78.4% [61.8, 90.2%] for determining non-response [area under the curve 0.85]. In the multivariable analysis, a >20% reduction had the highest odds ratio (22.6 [4.2, 201.2]; p = 0.001) for determining response. Similar results were seen for the rescue therapy outcome. CONCLUSIONS Changes in bowel wall thickness, after 48 ± 24 h following intravenous corticosteroid treatment in hospitalised patients with severe ulcerative colitis, identify responders with high accuracy and might be used as an early marker to guide accelerated rescue therapy.
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Affiliation(s)
- Johan F K F Ilvemark
- Department of Gastroenterology and Hepatology, Copenhagen University Hospital - Gentofte and Herlev, Herlev, Denmark
| | - Rune Wilkens
- Gastrounit, Medical Division, Copenhagen University Hospital, Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Copenhagen University Hospital - Amager and Hvidovre, Digestive Disease Centre, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Peter Thielsen
- Department of Gastroenterology and Hepatology, Copenhagen University Hospital - Gentofte and Herlev, Herlev, Denmark
| | - Anders Dige
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Trine Boysen
- Gastrounit, Medical Division, Copenhagen University Hospital -- Amager and Hvidovre, Hvidovre, Denmark
| | - Jørn Brynskov
- Department of Gastroenterology and Hepatology, Copenhagen University Hospital - Gentofte and Herlev, Herlev, Denmark
| | - Jacob Tveiten Bjerrum
- Department of Gastroenterology and Hepatology, Copenhagen University Hospital - Gentofte and Herlev, Herlev, Denmark
| | - Jakob Benedict Seidelin
- Department of Gastroenterology and Hepatology, Copenhagen University Hospital - Gentofte and Herlev, Herlev, Denmark
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23
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Kosaraju RS, Wong DJ, Roth EM, Cataldo TE, Fabrizio AC, Crowell KT, Feuerstein JD, Messaris E. Dose-Intensified Infliximab Rescue Therapy for Severe Ulcerative Colitis Does Not Reduce Short-term Colectomy Rates or Increase Postoperative Complications. Dis Colon Rectum 2022; 65:1232-40. [PMID: 35714346 DOI: 10.1097/DCR.0000000000002176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Dose-intensified rescue therapy with infliximab for hospitalized patients with ulcerative colitis has become increasingly popular in recent years. However, there is ongoing debate about both the efficacy of these regimens to reduce the rate of colectomy and the associated risks of increased infliximab exposure. OBJECTIVE The purpose of this study was to compare the colectomy and postoperative complication rates in hospitalized patients with severe ulcerative colitis receiving standard infliximab induction therapy (3 doses of 5 mg/kg at weeks 0, 2, and 6) and dose-intensified regimens including a higher weight-based dosing or more rapid interval. DESIGN This was a retrospective cohort study. SETTINGS This study was conducted at an academic tertiary care hospital. PATIENTS A total of 145 adult patients received inpatient rescue infliximab therapy for the treatment of ulcerative colitis between 2008 and 2020. MAIN OUTCOME MEASURES The primary outcome was colectomy rate within 3 months of rescue therapy. Secondary outcomes include mid-term colectomy rates, as well as perioperative complications in patients receiving colectomy within 3 months of rescue infliximab initiation. RESULTS The proportion of dose-intensified regimens increased over time. Unadjusted 3-month colectomy rates were 14% in patients who received standard rescue infliximab dosing, 16% in patients given a single dose-escalated dose, and 24% in patients given multiple inpatient dose-escalated doses. These rates were not statistically significantly different. Of the patients requiring colectomy within 3 months of infliximab rescue, those who received multiple inpatient doses of dose-escalated therapy had a higher percentage of colectomy during the initial hospitalization but a lower rate of perioperative complications. LIMITATIONS This study was limited by the use of retrospective data and the limited power to account for the heterogeneity of disease. CONCLUSIONS No significant difference was found in colectomy rates between patients receiving standard or dose-intensified regimens. However, dose-intensified regimens, including multiple inpatient doses given to patients with more severe disease, were not associated with a greater risk of perioperative complications. See Video Abstract at http://links.lww.com/DCR/B864 . LA TERAPIA DE RESCATE CON DOSIS INTENSIFICADA DE INFLIXIMAB EN COLITIS ULCEROSA GRAVE NO REDUCE LAS TASAS DE COLECTOMA A CORTO PLAZO NI AUMENTA LAS COMPLICACIONES POSOPERATORIAS ANTECEDENTES:La terapia de rescate de dosis intensificada con infliximab para pacientes hospitalizados con colitis ulcerosa se ha vuelto cada vez más popular en los últimos años. Sin embargo, existe un debate en curso sobre la eficacia de estos regímenes para reducir la tasa de colectomía y los riesgos asociados a una mayor exposición al infliximab.OBJETIVO:El propósito de este estudio fue comparar las tasas de colectomía y complicaciones posoperatorias en pacientes hospitalizados con colitis ulcerosa grave que recibieron terapia estándar de inducción de infliximab (3 dosis de 5 mg/kg en las semanas 0, 2, 6) y regímenes de dosis intensificada que incluyen una dosificación más alta basada en el peso o intervalo más rápido.DISEÑO:Fue un estudio de cohorte retrospectivo.ENTORNO CLÍNICO:Este estudio se realizó en un hospital académico de tercer nivel.PACIENTES:Un total de 145 pacientes adultos que recibieron terapia de rescate con infliximab para el tratamiento de la colitis ulcerosa entre 2008 y 2020.PRINCIPALES MEDIDAS DE VALORACIÓN:El resultado principal fue la tasa de colectomía dentro de los 3 meses posteriores a la terapia de rescate. Los resultados secundarios incluyen tasas de colectomía a mediano plazo, así como las complicaciones perioperatorias en pacientes que reciben colectomía dentro de los 3 meses posteriores al inicio de infliximab de rescate.RESULTADOS:La proporción de regímenes de dosis intensificada aumentó con el tiempo. Las tasas de colectomía de 3 meses no ajustadas fueron del 14% en los pacientes que recibieron dosis estándar de infliximab de rescate, del 16% en los pacientes que recibieron una dosis única escalonada y del 24% en los pacientes que recibieron múltiples dosis hospitalarias escalonadas. Estas tasas no fueron estadísticamente significativas. De los pacientes que requirieron colectomía dentro de los 3 meses posteriores al rescate de infliximab, aquellos que recibieron terapia de múltiples dosis hospitalarias escalonadas tuvieron un mayor porcentaje de colectomía durante la hospitalización inicial pero una menor tasa de complicaciones perioperatorias.LIMITACIONES:Datos retrospectivos y poder limitado para explicar la heterogeneidad de la enfermedad.CONCLUSIONES:No se encontraron diferencias significativas en las tasas de colectomía entre los pacientes que recibieron regímenes estándar o de dosis intensificada. Sin embargo, los regímenes de dosis intensificadas, incluidas múltiples dosis hospitalarias administradas a pacientes con enfermedad más grave, no se asociaron con un mayor riesgo de complicaciones perioperatorias. Consulte Video Resumen en http://links.lww.com/DCR/B864 . (Traducción-Dr. Ingrid Melo ).
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Démaris A, Widigson ESK, Ilvemark JFKF, Steenholdt C, Seidelin JB, Huisinga W, Michelet R, Aulin LBS, Kloft C. Ulcerative Colitis and Acute Severe Ulcerative Colitis Patients Are Overlooked in Infliximab Population Pharmacokinetic Models: Results from a Comprehensive Review. Pharmaceutics 2022; 14:2095. [PMID: 36297530 DOI: 10.3390/pharmaceutics14102095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/07/2022] [Accepted: 09/15/2022] [Indexed: 11/18/2022] Open
Abstract
Ulcerative colitis (UC) is part of the inflammatory bowels diseases, and moderate to severe UC patients can be treated with anti-tumour necrosis α monoclonal antibodies, including infliximab (IFX). Even though treatment of UC patients by IFX has been in place for over a decade, many gaps in modelling of IFX PK in this population remain. This is even more true for acute severe UC (ASUC) patients for which early prediction of IFX pharmacokinetic (PK) could highly improve treatment outcome. Thus, this review aims to compile and analyse published population PK models of IFX in UC and ASUC patients, and to assess the current knowledge on disease activity impact on IFX PK. For this, a semi-systematic literature search was conducted, from which 26 publications including a population PK model analysis of UC patients receiving IFX therapy were selected. Amongst those, only four developed a model specifically for UC patients, and only three populations included severe UC patients. Investigations of disease activity impact on PK were reported in only 4 of the 14 models selected. In addition, the lack of reported model codes and assessment of predictive performance make the use of published models in a clinical setting challenging. Thus, more comprehensive investigation of PK in UC and ASUC is needed as well as more adequate reports on developed models and their evaluation in order to apply them in a clinical setting.
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Spinelli A, Bonovas S, Burisch J, Kucharzik T, Adamina M, Annese V, Bachmann O, Bettenworth D, Chaparro M, Czuber-Dochan W, Eder P, Ellul P, Fidalgo C, Fiorino G, Gionchetti P, Gisbert JP, Gordon H, Hedin C, Holubar S, Iacucci M, Karmiris K, Katsanos K, Kopylov U, Lakatos PL, Lytras T, Lyutakov I, Noor N, Pellino G, Piovani D, Savarino E, Selvaggi F, Verstockt B, Doherty G, Raine T, Panis Y. ECCO Guidelines on Therapeutics in Ulcerative Colitis: Surgical Treatment. J Crohns Colitis 2022; 16:179-189. [PMID: 34635910 DOI: 10.1093/ecco-jcc/jjab177] [Citation(s) in RCA: 65] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This is the second of a series of two articles reporting the European Crohn's and Colitis Organisation [ECCO] evidence-based consensus on the management of adult patients with ulcerative colitis [UC]. The first article is focused on medical management, and the present article addresses medical treatment of acute severe ulcerative colitis [ASUC] and surgical management of medically refractory UC patients, including preoperative optimisation, surgical strategies, and technical issues. The article provides advice for a variety of common clinical and surgical conditions. Together, the articles represent an update of the evidence-based recommendations of the ECCO for UC.
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Affiliation(s)
- Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, and Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Stefanos Bonovas
- Department of Biomedical Sciences, and IRCCS Humanitas Research Hospital, Milan, Italy
| | - Johan Burisch
- Gastrounit, Medical Division, and Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Hvidovre Hospital, University of Copenhagen, Denmark
| | - Torsten Kucharzik
- Department of Gastroenterology, Lüneburg Hospital, University of Hamburg, Lüneburg, Germany
| | - Michel Adamina
- Department of Surgery, Clinic of Visceral and Thoracic Surgery, Cantonal Hospital Winterthur, Zurich.,Department of Biomedical Engineering, Clinical Research and Artificial Intelligence in Surgery, Faculty of Medicine, University of Basel, Allschwil, Switzerland
| | - Vito Annese
- Department of Gastroenterology, Fakeeh University Hospital, Dubai, UAE
| | - Oliver Bachmann
- Department of Internal Medicine I, Siloah St. Trudpert Hospital, Pforzheim.,Hannover Medical School, Hannover, Germany
| | - Dominik Bettenworth
- University Hospital Munster, Department of Medicine B - Gastroenterology and Hepatology, Munster, Germany
| | - Maria Chaparro
- Gastroenterology Unit, IIS-IP, Universidad Autónoma de Madrid [UAM], CIBEREHD, Madrid, Spain
| | - Wladyslawa Czuber-Dochan
- King's College London, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, London, UK
| | - Piotr Eder
- Department of Gastroenterology, Dietetics and Internal Medicine, Poznań University of Medical Sciences, and Heliodor Święcicki University Hospital, Poznań, Poland
| | - Pierre Ellul
- Department of Medicine, Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | - Catarina Fidalgo
- Gastroenterology Division, Hospital Beatriz Ângelo, Loures, Portugal
| | - Gionata Fiorino
- Department of Biomedical Sciences, Humanitas University, and IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | - Paolo Gionchetti
- IBD Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna DIMEC, University of Bologna, Bologna, Italy
| | - Javier P Gisbert
- Gastroenterology Unit, IIS-IP, Universidad Autónoma de Madrid [UAM], CIBEREHD, Madrid, Spain
| | - Hannah Gordon
- Department of Gastroenterology, Barts Health NHS Trust, Royal London Hospital, London, UK
| | - Charlotte Hedin
- Karolinska Institutet, Department of Medicine Solna, and Karolinska University Hospital, Department of Gastroenterology, Dermatovenereology and Rheumatology, Stockholm, Sweden
| | - Stefan Holubar
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Marietta Iacucci
- Institute of Immunology and Immunotherapy, University of Birmingham, and Division of Gastroenterology, University Hospitals Birmingham NHS Trust, Birmingham, UK
| | | | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, Division of Internal Medicine, University and Medical School of Ioannina, Ioannina, Greece
| | - Uri Kopylov
- Department of Gastroenterology, Tel-HaShomer Sheba Medical Center, Ramat Gan, and Sackler Medical School, Tel Aviv, Israel
| | - Peter L Lakatos
- Division of Gastroenterology, McGill University Health Centre, Montreal, QC, Canada.,1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Theodore Lytras
- School of Medicine, European University Cyprus, Nicosia, Cyprus
| | - Ivan Lyutakov
- Department of Gastroenterology, University Hospital 'Tsaritsa Yoanna - ISUL', Medical University Sofia, Sofia, Bulgaria
| | - Nurulamin Noor
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Universitá degli Studi della Campania "Luigi Vanvitelli", Naples, Italy, and Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Daniele Piovani
- Department of Biomedical Sciences, Humanitas University, and IRCCS Humanitas Research Hospital, Milan, Italy
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Francesco Selvaggi
- Department of Advanced Medical and Surgical Sciences, Universitá degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Department of Chronic Diseases, Metabolism and Ageing, TARGID - IBD, KU Leuven, Leuven, Belgium
| | - Glen Doherty
- Department of Gastroenterology and Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Tim Raine
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Yves Panis
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Clichy and Université of Paris, France
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Con D, Vasudevan A, van Langenberg DR. Predictive Scores in Acute Severe Ulcerative Colitis: Which, What, and When are the Decision Points We Should Target? Clin Gastroenterol Hepatol 2022; 20:e344-e345. [PMID: 33905768 DOI: 10.1016/j.cgh.2021.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 04/22/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Danny Con
- Department of Gastroenterology, Eastern Health, Melbourne, Victoria, Australia
| | - Abhinav Vasudevan
- Department of Gastroenterology, Eastern Health, Melbourne, Victoria, Australia
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Nones RB, Fleshner PR, Queiroz NSF, Cheifetz AS, Spinelli A, Danese S, Peyrin-Biroulet L, Papamichael K, Kotze PG. Therapeutic Drug Monitoring of Biologics in IBD: Essentials for the Surgical Patient. J Clin Med 2021; 10:jcm10235642. [PMID: 34884344 PMCID: PMC8658146 DOI: 10.3390/jcm10235642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 11/22/2021] [Accepted: 11/24/2021] [Indexed: 12/11/2022] Open
Abstract
Despite significant development in the pharmacological treatment of inflammatory bowel diseases (IBD) along with the evolution of therapeutic targets and treatment strategies, a significant subset of patients still requires surgery during the course of the disease. As IBD patients are frequently exposed to biologics at the time of abdominal and perianal surgery, it is crucial to identify any potential impact of biological agents in the perioperative period. Even though detectable serum concentrations of biologics do not seem to increase postoperative complications after abdominal procedures in IBD, there is increasing evidence on the role of therapeutic drug monitoring (TDM) in the perioperative setting. This review aims to provide a comprehensive summary of published studies reporting the association of drug concentrations and postoperative outcomes, postoperative recurrence (POR) after an ileocolonic resection for Crohn’s disease (CD), colectomy rates in ulcerative colitis (UC), and perianal fistulizing CD outcomes in patients treated with biologics. Current data suggest that serum concentrations of biologics are not associated with an increased risk in postoperative complications following abdominal procedures in IBD. Moreover, higher concentrations of anti-TNF agents are associated with a reduction in colectomy rates in UC. Finally, higher serum drug concentrations are associated with reduced rates of POR after ileocolonic resections and increased rates of perianal fistula healing in CD. TDM is being increasingly used to guide clinical decision making with favorable outcomes in many clinical scenarios. However, given the lack of high quality data deriving mostly from retrospective studies, the evidence supporting the systematic application of TDM in the perioperative setting is still inconclusive.
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Affiliation(s)
- Rodrigo Bremer Nones
- Health Sciences Postgraduate Program, School of Medicine, Pontifical Catholic University of Paraná (PUCPR), Curitiba 80215-901, Brazil;
| | - Phillip R. Fleshner
- Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA;
| | | | - Adam S. Cheifetz
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA; (A.S.C.); (K.P.)
| | - Antonino Spinelli
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy;
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy;
| | - Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy;
- IBD Centre, Humanitas Research Hospital, 20089 Milan, Italy
| | | | - Konstantinos Papamichael
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA; (A.S.C.); (K.P.)
| | - Paulo Gustavo Kotze
- Health Sciences Postgraduate Program, School of Medicine, Pontifical Catholic University of Paraná (PUCPR), Curitiba 80215-901, Brazil;
- IBD Outpatient Clinics, Pontifical Catholic University of Paraná (PUCPR), Curitiba 80215-901, Brazil
- Correspondence:
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Dulai PS, Jairath V. A Microsimulation Model to Project the 5-Year Impact of Using Hyperbaric Oxygen Therapy for Ulcerative Colitis Patients Hospitalized for Acute Flares. Dig Dis Sci 2021; 66:3740-3752. [PMID: 33185788 PMCID: PMC9035275 DOI: 10.1007/s10620-020-06707-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 11/02/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Hyperbaric oxygen therapy (HBOT) improves short-term outcomes for ulcerative colitis (UC) patients hospitalized for acute flares. Longer-term impacts and cost-effectiveness are unknown. METHODS We compared disease outcomes and cost-effectiveness of HBOT in addition to standard of care versus standard of care alone for UC patients hospitalized for acute flares using a microsimulation model. Published literature was used for transition probabilities, costs, and quality-adjusted life year (QALY) estimates. We modeled 100,000 individuals in each group over a 5-year horizon and compared rates of re-hospitalization, rescue medical therapy, colectomy, death, and cost-effectiveness at a willingness-to-pay of $100,000/QALY. Probabilistic sensitivity analyses were performed with 500 samples and 250 trials, in addition to multiple microsimulation sensitivity analyses. RESULTS The use of HBOT at the time of index hospitalization for an acute UC flare is projected to reduce the risk of re-hospitalization, inpatient rescue medical therapy, and inpatient emergent colectomy by over 60% (p < 0.001) and mortality by over 30% (p <0.001), during a 5-year horizon. The HBOT strategy costs more ($5600 incremental cost) but also yielded higher QALYs (0.13 incremental yield), resulting in this strategy being cost-effective ($43,000/QALY). Results were sensitive to HBOT costs and rates of endoscopic improvement with HBOT. Probabilistic sensitivity analyses observed HBOT to be more cost-effective than standard of care in 95% of iterations. CONCLUSION The use of HBOT to optimize response to steroids during the index hospitalization for an acute UC flare is cost-effective and is projected to result in significant reductions in disease-related complications in the long term.
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Affiliation(s)
- Parambir S Dulai
- Division of Gastroenterology, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093, USA.
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Holvoet T, Lobaton T, Hindryckx P. Optimal Management of Acute Severe Ulcerative Colitis (ASUC): Challenges and Solutions. Clin Exp Gastroenterol 2021; 14:71-81. [PMID: 33727846 PMCID: PMC7955027 DOI: 10.2147/ceg.s197719] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 12/14/2020] [Indexed: 12/25/2022] Open
Abstract
Acute severe colitis is a severe complication of ulcerative colitis, affecting approximately 20% of patients. For physicians, it remains a challenging condition to treat. Current treatment algorithms have diminished the mortality associated with acute severe ulcerative colitis (ASUC), but colectomy rates remain high (approximately 30%) despite advances in therapy. Colectomy in ASUC is particularly associated with important postoperative complications and morbidity. In this review, reasons for the inability to improve care and avoid evolution to colectomy for ASUC are explored and solutions that might lead to a better management of the disease are investigated.
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Affiliation(s)
- Tom Holvoet
- Department of Gastroenterology, AZ Nikolaas, Sint-Niklaas, Belgium.,Department of Gastroenterology, University Hospital Ghent, Ghent, Belgium
| | - Triana Lobaton
- Department of Gastroenterology, University Hospital Ghent, Ghent, Belgium
| | - Pieter Hindryckx
- Department of Gastroenterology, University Hospital Ghent, Ghent, Belgium
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Con D, Andrew B, Nicolaides S, van Langenberg DR, Vasudevan A. Biomarker dynamics during infliximab salvage for acute severe ulcerative colitis: C-reactive protein (CRP)-lymphocyte ratio and CRP-albumin ratio are useful in predicting colectomy. Intest Res 2021; 20:101-113. [PMID: 33902267 PMCID: PMC8831766 DOI: 10.5217/ir.2020.00146] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/22/2021] [Indexed: 11/21/2022] Open
Abstract
Background/Aims The residual risk of colectomy after infliximab salvage in steroid-refractory acute severe ulcerative colitis (ASUC) is required to inform the need for subsequent maintenance biologic therapy. The aim of this study was to determine the dynamic response of common serum biomarkers to infliximab salvage and assess their utility in predicting subsequent colectomy. Methods A retrospective single-center cohort study was conducted on all patients who received infliximab salvage for steroid-refractory ASUC between January 1, 2010, and July 31, 2019. Biomarkers were assessed on admission and days 1 and 3 post infliximab, and included C-reactive protein (CRP)-albumin-ratio (CAR), CRP-lymphocyte-ratio (CLR), platelet-lymphocyte-ratio (PLR) and neutrophil-lymphocyte-ratio (NLR). Results Of 94 patients (median age, 35 years; 67% of male), 20% required colectomy at 12 months. Biomarkers on day 3 post-infliximab best differentiated nonresponders, who had higher CRP, lower albumin and lower lymphocyte count (each P < 0.05). Day 3 predictive performance (area under the curve) for 12-month colectomy was best for CAR (0.871) and CLR (0.874), which were similar to Lindgren (0.829; P > 0.05) but superior to Mayo (0.726), partial Mayo (0.719), PLR (0.719), Ho index (0.714), NLR (0.675), Travis score (0.657) and endoscopic Mayo (0.609) (each P < 0.05). A day 3 CAR cutoff of 0.47 mg/g had 79% sensitivity, 80% specificity, 94% negative predictive value (NPV) to predict colectomy; while a day 3 CLR cutoff of 6.0 mg/109 had 84% sensitivity, 84% specificity, 96% NPV. Conclusions CAR and CLR measured on day 3 post infliximab salvage for steroid-refractory ASUC represent simple and routinely performed biomarkers that appear to be strong predictors of colectomy. Prospective studies are required to confirm the utility of these predictive scores.
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Affiliation(s)
- Danny Con
- Department of Gastroenterology, Eastern Health, Melbourne, Australia
| | - Bridgette Andrew
- Department of Gastroenterology, Eastern Health, Melbourne, Australia
| | - Steven Nicolaides
- Department of Gastroenterology, Eastern Health, Melbourne, Australia
| | - Daniel R van Langenberg
- Department of Gastroenterology, Eastern Health, Melbourne, Australia.,Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Australia
| | - Abhinav Vasudevan
- Department of Gastroenterology, Eastern Health, Melbourne, Australia.,Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Australia
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Battat R, Hemperly A, Truong S, Whitmire N, Boland BS, Dulai PS, Holmer AK, Nguyen NH, Singh S, Vande Casteele N, Sandborn WJ. Baseline Clearance of Infliximab Is Associated With Requirement for Colectomy in Patients With Acute Severe Ulcerative Colitis. Clin Gastroenterol Hepatol 2021; 19:511-518.e6. [PMID: 32348905 PMCID: PMC7606215 DOI: 10.1016/j.cgh.2020.03.072] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 03/06/2020] [Accepted: 03/27/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Hospitalized patients with acute severe ulcerative colitis (ASUC) often require surgery. Although the tumor necrosis factor antagonist infliximab is an effective salvage therapy to prevent colectomy in patients with ASUC, optimal dosing is unclear. Calculated infliximab clearance has been associated with important outcomes in patients with ulcerative colitis, but its utility in patients with ASUC has not been established. We assessed the relationship between calculated the baseline infliximab clearance before infliximab salvage therapy and the requirement for colectomy in patients hospitalized for ASUC. METHODS We obtained data from hospitalized patients with ASUC who initiated infliximab therapy. We then calculated the baseline infliximab drug clearance in these patients based on an existing formula. The primary aim was to compare clearance between patients who required colectomy 6 months later and patients who did not require colectomy. Receiver operating characteristic curve analyses evaluated clearance thresholds for colectomy. Multivariable logistic regression analysis evaluated factors associated with colectomy. RESULTS In 39 patients with ASUC, the median baseline calculated clearance was higher in patients requiring colectomy at 6 months than in patients without colectomy (0.733 vs 0.569 L/d; P = .005). An infliximab clearance threshold of 0.627 L/d identified patients who required colectomy with 80.0% sensitivity and 82.8% specificity (area under the curve, 0.80). A higher proportion of patients with infliximab clearance of 0.627 L/d or more underwent colectomy within 6 months (61.5%) than patients with lower infliximab clearance values (7.7%) (P = .001). Multivariable analysis identified baseline infliximab clearance as the only factor associated with colectomy. The infliximab dose in the hospital was higher in patients who required colectomy. Results were similar at 30 days and 1 year. CONCLUSIONS In patients hospitalized with ASUC, higher values of calculated infliximab clearance before infliximab administration is associated with higher rates of colectomy. Although patients who required colectomies received higher doses, data on infliximab concentrations are lacking. Infliximab pharmacokinetic models are needed for patients with ASUC to allow comparative trials on clearance-based vs standard dosing.
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Affiliation(s)
- Robert Battat
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, California; Jill Roberts Center for Inflammatory Bowel Disease, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York
| | - Amy Hemperly
- Division of Gastroenterology, Department of Pediatrics, Rady Children's Hospital University of California, San Diego, La Jolla, California
| | - Stephanie Truong
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Natalie Whitmire
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Brigid S Boland
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Parambir S Dulai
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Ariela K Holmer
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Nghia H Nguyen
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Siddharth Singh
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Niels Vande Casteele
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - William J Sandborn
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, California.
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Rubin DT, Traboulsi C, Rai V. A Practical Clinical Approach to the Management of High-Risk Ulcerative Colitis. Gastroenterol Hepatol (N Y) 2021; 17:59-66. [PMID: 34035764 PMCID: PMC8132723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Patients with ulcerative colitis (UC) can experience periods of recurrent disease activity with a range of symptoms, including abdominal pain, rectal bleeding, urgency, and diarrhea. Although long-term remission will be achieved and maintained in most cases, the course of UC varies from patient to patient. Patients can be defined according to whether they are in remission or have mild, moderate, severe, or fulminant disease, and hospitalization can occur under different circumstances. In these cases, determining the next course of therapy is essential. The aim of this article is to present an approach to the treatment of high-risk UC in both the outpatient and inpatient settings. Also presented is a critical appraisal of alternative and emerging approaches to the management of patients with high-risk UC. Fundamental principles are key in the management of high-risk UC, including discussing the goals of treatment with the patient and family, assessing each patient's risk level and prognostic factors in addition to disease activity to inform therapeutic choices, understanding drug mechanisms and pharmacokinetics, and using objective measures to monitor disease response. In the treatment of all patients with high-risk UC, a balanced approach to deciding between medical and surgical options must be maintained.
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Affiliation(s)
- David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, Illinois
| | - Cindy Traboulsi
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, Illinois
| | - Victoria Rai
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, Illinois
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Li JR, Ling FM, Chen YD, Xu MY, Zhu LR. Treatment of acute severe ulcerative colitis. Shijie Huaren Xiaohua Zazhi 2021; 29:87-92. [DOI: 10.11569/wcjd.v29.i2.87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Acute severe ulcerative colitis (ASUC) is a potentially life-threatening medical emergency. Due to the increasing incidence of ulcerative colitis in recent years, ASUC has become increasingly common in clinical practice. Presently, corticosteroids remain the first choice, whose efficacy should be evaluated after 3 d. If unsatisfactory, it should be switched to infliximab or cyclosporine salvage treatment timely. Besides, colectomy may be an option when medical treatment is ineffective or serious complications occur. This review describes the current treatment regimens for ASUC, with an aim to help develop treatment plans and improve the prognosis and life quality of patients with ASUC .
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Affiliation(s)
- Jun-Rong Li
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Fang-Mei Ling
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Yi-Dong Chen
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Ming-Yang Xu
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Liang-Ru Zhu
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
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Abstract
Acute severe ulcerative colitis [ASUC] remains a common medical emergency, with 25% of patients with ulcerative colitis experiencing at least one event in their disease course. Despite advances in medical therapy, ASUC continues to be associated with considerable morbidity and mortality, with up to 30% of patients requiring colectomy during initial admission. Our aim was to review the current controversies and recent progress in risk stratification, prediction of outcome, and personalisation of care in ASUC. We re-assess the use of Truelove and Witts' criteria, serum biomarkers, and the use of composite clinical indices in current clinical practice. We explore the potential for endoscopic prediction using defined validated indices for accurate and early prognostication, and the need to define outcome. We also consider the impact of the current COVID-19 pandemic. Finally, we discuss the current research agenda, including the application of new and emerging biomarkers coupled with multi-omics and the implications in management and optimisation of outcome. Research priorities for the prediction of outcome in acute severe colitis include the following. 1. Development of an accurate admission score to guide early medical rescue therapy or colectomy. 2. Utility of point-of-care faecal calprotectin, with determination of optimal cut-off values. 3. Role of serum and faecal infliximab levels to both predict outcome and guide accelerated infliximab dosing. 4. Role of novel biomarkers, including serum calprotectin, in predicting response to corticosteroids or rescue therapy. 5. Specific predictors of response to ciclosporin and infliximab to allow rationalisation of drug use. 6. Utility of validated endoscopic scores. 7. Utility of radiological assessment beyond use of plain abdominal X-ray. 8. The use of multiomics and machine learning to predict risk of Acute Severe Colitis in patients with Ulcerative Colitis.
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Affiliation(s)
- Vipin Gupta
- Translational Gastroenterology Unit, Nuffield Department of Experimental Medicine, University of Oxford, Oxford, UK,Department Of Gastroenterology, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, UK
| | - Waled Mohsen
- Translational Gastroenterology Unit, Nuffield Department of Experimental Medicine, University of Oxford, Oxford, UK,Digestive Diseases Unit, Gold Coast University Hospital, Queensland, Australia,Corresponding author: Waled Mohsen,
| | - Thomas P Chapman
- Translational Gastroenterology Unit, Nuffield Department of Experimental Medicine, University of Oxford, Oxford, UK,Department of Gastroenterology, Western Sussex Hospitals NHS Foundation Trust, Worthing, UK
| | - Jack Satsangi
- Translational Gastroenterology Unit, Nuffield Department of Experimental Medicine, University of Oxford, Oxford, UK
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Abstract
Five biologics are approved for the treatment of ulcerative colitis (UC): infliximab, adalimumab, golimumab, vedolizumab, and ustekinumab. These drugs have varying levels of efficacy and are recommended as first-line treatment of moderate to severe UC. There has been only 1 head-to-head trial comparing the efficacy of the biologics, adalimumab and vedolizumab, which has important implications for management. Therapeutic drug monitoring of biologics, especially anti-TNF alpha agents, may improve the long-term efficacy of these agents. The future of treatment may include personalization of medications, based on patient-specific and disease-specific characteristics as well as biomarkers, along with appropriate therapeutic drug monitoring.
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Lima CCG, Queiroz NSF, Sobrado CW, Silva GLR, Nahas SC. CRITICAL ANALYSIS OF ANTI-TNF USE IN THE ERA OF NEW BIOLOGICAL AGENTS IN INFLAMMATORY BOWEL DISEASE. Arq Gastroenterol 2020; 57:323-332. [PMID: 33027484 DOI: 10.1590/s0004-2803.202000000-59] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 06/29/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Inflammatory bowel diseases (IBD), both Crohn's disease and ulcerative colitis, are chronic immune-mediated diseases that present a relapsing and remitting course and requires long-term treatment. Anti-tumor necrosis factor (anti-TNF) therapy has changed the management of the disease by reducing the need for hospitalizations, surgeries and improving patient´s quality of life. OBJECTIVE The aim of this review is to discuss the role of anti-TNF agents in IBD, highlighting the situations where its use as first-line therapy would be appropriate. METHODS Narrative review summarizing the best available evidence on the topic based on searches in databases such as MedLine and PubMed up to April 2020 using the following keywords: "inflammatory bowel disease'', "anti-TNF agents" and ''biologic therapy''. CONCLUSION Biological therapy remains the cornerstone in the treatment of IBD. In the absence of head-to-head comparisons, the choice of the biological agent may be challenging and should take into account several variables. Anti-TNF agents should be considered as first line therapy in specific scenarios such as acute severe ulcerative colitis, fistulizing Crohn's disease and extra-intestinal manifestations of IBD, given the strong body of evidence supporting its efficacy and safety in these situations.
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Affiliation(s)
- Camila Cunha Gonzaga Lima
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, São Paulo, SP, Brasil
| | | | - Carlos Walter Sobrado
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia e Divisão de Coloproctologia, São Paulo, SP, Brasil
| | - Gustavo Luís Rodela Silva
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia e Divisão de Endoscopia Digestiva, São Paulo, SP, Brasil
| | - Sérgio Carlos Nahas
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia e Divisão de Coloproctologia, São Paulo, SP, Brasil
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Gibson DJ, Doherty J, McNally M, Campion J, Keegan D, Keogh A, Kennedy U, Byrne K, Egan LJ, McKiernan S, MacCarthy FI, Sengupta S, Sheridan J, Mulcahy HE, Cullen G, Slattery E, Kevans D, Doherty GA. Comparison of medium to long-term outcomes of acute severe ulcerative colitis patients receiving accelerated and standard infliximab induction. Frontline Gastroenterol 2020; 11:441-447. [PMID: 33104766 PMCID: PMC7569515 DOI: 10.1136/flgastro-2019-101335] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 11/12/2019] [Accepted: 11/22/2019] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Accelerated dose infliximab (IFX) induction is associated with reduced short-term colectomy rate in acute severe ulcerative colitis (ASUC). Data on medium/long-term outcomes of this strategy are limited. AIMS Evaluate medium/long-term outcomes in patients receiving IFX induction for ASUC, comparing accelerated dose (AD) and standard dose (SD) induction. METHODS Retrospective study of consecutive patients admitted with corticosteroid-refractory ASUC in four tertiary referral centres within INITIative IBD research network (www.initiativeibd.ie). IFX rescue was given either as SD (weeks 0, 2, 6) or AD (<28 days) from January 2010 to September 2017. AD induction has been utilised in participating centres since 2014. Consequently SD patients were subdivided based on time period of IFX rescue: historical SD group (SD1) (2010-2013) and current SD group (SD2) (2014-2017). Primary endpoint was time to colectomy; secondary endpoint was time to IFX discontinuation if induction was complete. RESULTS 145 patients received rescue IFX (AD=58, SD1=32, SD2=55). Disease severity at induction was comparable between AD and SD1 groups; however, SD2 group had less severe disease: median C-reactive protein (CRP) 39, 44 and 20 mg/L for AD, SD1 and SD2 groups, respectively (p=0.026, Kruskal-Wallis); median CRP: albumin ratio was 1.4, 1.8 and 0.6 (p=0.016). Median follow-up for AD, SD1 and SD2 groups was 1.6 (IQR 1.1-3.1), 4.9 (IQR 2.6-5.5) and 1.5 (IQR 0.9-2.3) years. Time to colectomy was shorter in SD1 (log rank p=0.0013); no significant difference in time to colectomy was observed comparing AD and SD2 groups (log rank p=0.32). 123 patients (84%) completed IFX induction and received maintenance therapy. Time to IFX discontinuation was shorter in SD1 (log rank p=0.009). CONCLUSION Time to colectomy is significantly prolonged with use of AD IFX in selected ASUC patients with more severe disease. Historical use of standard IFX induction for all ASUC patients is associated with inferior long-term outcomes.
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Affiliation(s)
- David J Gibson
- Department of Gastroenterology, Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Jayne Doherty
- Department of Gastroenterology, Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Mairead McNally
- Department of Gastroenterology, University Hospital Galway, Galway, Galway, Ireland
| | - John Campion
- Department of Gastroenterology, St James' Hospital, Dublin, Ireland
| | - Denise Keegan
- Department of Gastroenterology, Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Aine Keogh
- Department of Gastroenterology, University Hospital Galway, Galway, Galway, Ireland
| | - Una Kennedy
- Department of Gastroenterology, St James' Hospital, Dublin, Ireland
| | - Kathryn Byrne
- Department of Gastroenterology, Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Laurence J Egan
- Department of Gastroenterology, University Hospital Galway, Galway, Galway, Ireland
- Department of Pharmacology and Therapeutics, National University of Ireland Galway, Galway, Ireland
| | - Susan McKiernan
- Department of Gastroenterology, St James' Hospital, Dublin, Ireland
| | - FInbar MacCarthy
- Department of Gastroenterology, St James' Hospital, Dublin, Ireland
| | - Subhasish Sengupta
- Department of Gastroenterology, Our Lady of Lourdes Hospital, Drogheda, Ireland
| | - Juliette Sheridan
- Department of Gastroenterology, Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Hugh E Mulcahy
- Department of Gastroenterology, Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Garret Cullen
- Department of Gastroenterology, Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Eoin Slattery
- Department of Gastroenterology, University Hospital Galway, Galway, Galway, Ireland
| | - David Kevans
- Department of Gastroenterology, St James' Hospital, Dublin, Ireland
| | - Glen A Doherty
- Department of Gastroenterology, Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
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Oh SJ, Shin GY, Soh H, Lee JG, Im JP, Eun CS, Lee KM, Park DI, Han DS, Kim HJ, Lee CK. Long-term outcomes of infliximab in a real-world multicenter cohort of patients with acute severe ulcerative colitis. Intest Res 2020; 19:323-331. [PMID: 32806875 PMCID: PMC8322032 DOI: 10.5217/ir.2020.00039] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/03/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/AIMS Infliximab (IFX) has proven effective as rescue therapy in steroid-refractory acute severe ulcerative colitis (ASUC), however, the long-term real-world data are scarce. Our study aimed to assess the long-term treatment outcomes of IFX in a real-life cohort. METHODS We established a multicenter retrospective cohort of hospitalized patients with ASUC, who met Truelove and Witt's criteria and received intravenous corticosteroid (IVCS) or IFX during index hospitalization between 2006 and 2016 in 5 university hospitals in Korea. The cohort was systematically followed up until colectomy, death or last follow-up visit. RESULTS A total of 296 patients were followed up for a mean of 68.9 ± 44.0 months. During index hospitalization, 49 patients were treated with IFX; as rescue therapy for IVCS failure in 37 and as first-line medical therapy for ASUC in 12. All patients treated with IFX avoided colectomy during index hospitalization. The cumulative rates of rehospitalization and colectomy were 20.4% and 6.1% at 3 months and 39.6% and 18.8% at the end of follow-up, respectively. Patients treated with IFX presented with significantly shorter colectomy-free survival than IVCS responders (P= 0.04, log-rank test). Both cytomegalovirus colitis and Clostridioides difficile infection (CDI) were the significant predictors of colectomy in the overall study cohort (hazard ratios of 6.57 and 4.61, respectively). There were no fatalities. CONCLUSIONS Our real-world cohort study demonstrated that IFX is an effective therapeutic option in Korean patients with ASUC, irrespective of IFX indication. Aggressive vigilance for cytomegalovirus colitis and CDI is warranted for hospitalized patients with ASUC.
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Affiliation(s)
- Shin Ju Oh
- Center for Crohn's and Colitis, Department of Gastroenterology, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
| | - Ga Young Shin
- Center for Crohn's and Colitis, Department of Gastroenterology, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
| | - Hosim Soh
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Gon Lee
- Department of Gastroenterology, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Jong Pil Im
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Chang Soo Eun
- Department of Gastroenterology, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Kang-Moon Lee
- Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Dong Il Park
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Soo Han
- Department of Gastroenterology, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Hyo Jong Kim
- Center for Crohn's and Colitis, Department of Gastroenterology, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
| | - Chang Kyun Lee
- Center for Crohn's and Colitis, Department of Gastroenterology, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
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Buhl S, Dorn-Rasmussen M, Brynskov J, Ainsworth MA, Bendtzen K, Klausen PH, Bolstad N, Warren DJ, Steenholdt C. Therapeutic thresholds and mechanisms for primary non-response to infliximab in inflammatory bowel disease. Scand J Gastroenterol 2020; 55:884-890. [PMID: 32631131 DOI: 10.1080/00365521.2020.1786852] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Primary non-response to infliximab (IFX) inherits a poor prognosis in inflammatory bowel disease (IBD). We explored underlying mechanisms and therapeutic thresholds in an effort to provide basis for optimizing therapy. METHODS A prospectively followed cohort of 166 IBD patients having received standard IFX induction therapy (5 mg/kg at weeks 2, 6, and 14) had trough IFX and anti-IFX antibodies (Abs) retrospectively assessed at weeks 2 (n = 148) and 6 (n = 108). Circulating TNFα was measured in matched primary non-responders (n = 29) and responders (n = 21) at baseline and weeks 6 and 14. Clinical outcome at week 14 was supported by disease activity scores in half of patients. RESULTS In all, 18 patients (11%) had primary non-response. Infliximab was consistently lower throughout the induction phase in non-responders as compared to responders (Week 2: IFX median 18.9 μg/mL vs. 23.3, p < .05. Week 6: 8.4 vs. 17.0, p < .05). Optimal IFX thresholds associated with response was 22.9 μg/mL at week 2 (sensitivity 51%, specificity 80%, AUCROC 0.67, p < .05) and 11.8 at week 6 (72%, 77%, 0.71, p < .05). Anti-IFX Abs occurred in 28% of primary non-responders and associated with low IFX and treatment failure (OR 13.7 [2.8-67.5], p < .01). Markers of disease activity (disease activity scores, albumin, CRP) also associated with low IFX. Circulating TNFα was higher throughout induction in non-responders with ulcerative colitis but not Crohn's disease. CONCLUSION IBD patients with primary IFX failure generally have lower IFX trough than responders during early induction phase. Pharmacokinetic failure seems common in ulcerative colits, whereas pharmacodynamic failure appears common in Crohn's disease.
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Affiliation(s)
- Sine Buhl
- Department of Gastroenterology, Copenhagen University Hospital Herlev, Herlev, Denmark
| | - Maria Dorn-Rasmussen
- Department of Gastroenterology, Copenhagen University Hospital Herlev, Herlev, Denmark
| | - Jørn Brynskov
- Department of Gastroenterology, Copenhagen University Hospital Herlev, Herlev, Denmark
| | - Mark A Ainsworth
- Department of Gastroenterology, Copenhagen University Hospital Herlev, Herlev, Denmark
| | - Klaus Bendtzen
- Institute for Inflammation Research, Rigshospitalet, Copenhagen, Denmark
| | - Pia Helene Klausen
- Department of Gastroenterology, Copenhagen University Hospital Herlev, Herlev, Denmark
| | - Nils Bolstad
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - David J Warren
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Casper Steenholdt
- Department of Gastroenterology, Copenhagen University Hospital Herlev, Herlev, Denmark
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Abstract
PURPOSE OF REVIEW In this review article, we address emerging evidence for the medical and surgical treatment of the hospitalized patient with ulcerative colitis. RECENT FINDINGS Ulcerative colitis is a chronic inflammatory disease involving the colon and rectum. About one-fifth of patients will be hospitalized from ulcerative colitis, and about 20-30%, experiencing an acute flare will undergo colectomy. Because of the significant clinical consequences, patients hospitalized need prompt evaluation for potential complications, stratification of disease severity, and a multidisciplinary team approach to therapy, which involves both the gastroenterologist and surgeon. Although corticosteroids remain first-line therapy, second-line medical rescue options, primarily infliximab or cyclosporine, are considered within 3-5 days of presentation. In conjunction, an early surgical consultation to present the possibility of a staged proctocolectomy as one of the therapeutic options is equally important. SUMMARY A coordinated multidisciplinary, individualized approach to treatment, involving the patient preferences throughout the process, is optimal in providing patient-centered effective care.
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Abstract
Biologic therapies have revolutionized the management of inflammatory bowel disease [IBD], but primary and secondary non-responses occur in a significant proportion of patients. Therapeutic drug monitoring [TDM] now has an established role in the treatment algorithm for managing secondary loss of response to anti-tumour necrosis factor [anti-TNF] agents during maintenance therapy. Data to support the use of TDM in the management of secondary loss of response to vedolizumab and ustekinumab are emerging. The potential to prevent primary non-response to biologic agents during induction is of equal, and potentially greater, clinical importance. Again, most data supporting the use of 'proactive' TDM during induction pertains to the use of anti-TNF agents, but signals of efficacy for the use of TDM during induction with other biologic classes are now appearing. This review aims to summarize data on the use of TDM during induction to prevent pharmacokinetic primary non-response to all three classes of biologic therapy currently available for the treatment of IBD.
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Affiliation(s)
- Miles P Sparrow
- Department of Gastroenterology, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Konstantinos Papamichael
- Division of Gastroenterology, Center for Inflammatory Bowel Disease, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Mark G Ward
- Department of Gastroenterology, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | | | - David Laharie
- Gastroenterology Unit, Pessac University Hospital, France
| | - Stephane Paul
- Department of Immunology, University Hospital of Saint Etienne, Saint-Etienne, France
| | - Xavier Roblin
- Gastroenterology Unit, University Hospital of Saint Etienne, Saint-Etienne, France
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Li H, Tian F. Toxic Epidermal Necrolysis Because of Various Herpesviruses Infection After Accelerated Infliximab Induction in a Chinese Patient With Acute Severe Ulcerative Colitis. Inflamm Bowel Dis 2020; 26:e38-e40. [PMID: 32086936 DOI: 10.1093/ibd/izaa034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Hui Li
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Feng Tian
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
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Abstract
A subset of patients with ulcerative colitis (UC) present with, or progress to, moderate to severe disease activity. These patients are at high risk for colectomy, hospitalization, corticosteroid dependence, and serious infections. The risk of life-threatening complications and emergency colectomy is particularly high among those patients hospitalized with acute severe ulcerative colitis. Optimal management of outpatients or inpatients with moderate to severe UC often requires the use of immunomodulator and/or biologic therapies, including thiopurines, methotrexate, cyclosporine, tacrolimus, TNF-α antagonists, vedolizumab, tofacitnib, or ustekinumab, either as monotherapy or in combination (with immunomodulators), to mitigate these risks. Decisions about optimal drug therapy in moderate to severe UC are complex, with limited guidance on comparative efficacy and safety of different treatments, leading to considerable practice variability. Therefore, the American Gastroenterological Association prioritized development of clinical guidelines on this topic. To inform the clinical guidelines, this technical review was completed in accordance with the Grading of Recommendations Assessment, Development and Evaluation framework. Focused questions in adult outpatients with moderate to severe UC included: (1) overall and comparative efficacy of different medications for induction and maintenance of remission in patients with or without prior exposure to TNF-α antagonists, (2) comparative efficacy and safety of biologic monotherapy vs combination therapy with immunomodulators, (3) comparative efficacy of top-down (upfront use of biologics and/or immunomodulator therapy) vs step-up therapy (acceleration to biologic and/or immunomodulator therapy only after failure of 5-aminosalicylates, and (4) role of continuing vs stopping 5-aminosalicylates in patients being treated with immunomodulator and/or biologic therapy for moderate to severe UC. Focused questions in adults hospitalized with acute severe ulcerative colitis included: (5) overall and comparative efficacy of pharmacologic interventions for inpatients refractory to corticosteroids, in reducing risk of colectomy, (6) optimal dosing regimens for intravenous corticosteroids and infliximab in these patients, and (7) role of adjunctive antibiotics in the absence of confirmed infections.
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Affiliation(s)
- Siddharth Singh
- Division of Gastroenterology, University of California, San Diego, La Jolla, California
| | - Jessica R Allegretti
- Division of Gastroenterology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Shazia Mehmood Siddique
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jonathan P Terdiman
- Division of Gastroenterology, University of California, San Francisco, California
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45
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Moore H, Dolce P, Devas N, Baldassano R, Martinelli M. Post-induction infliximab trough levels and disease activity in the clinical evolution of pediatric ulcerative colitis. United European Gastroenterol J 2020; 8:425-435. [PMID: 32213038 DOI: 10.1177/2050640620912877] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND AND AIMS Recent adult evidence suggests that infliximab (IFX) trough levels (TL) in patients with severe ulcerative colitis (UC) may be decreased. The aims of our study were to compare post-induction IFX TL of children with severe versus moderate UC and to evaluate short- and long-term outcomes. METHODS In this single-center retrospective study, children with a diagnosis of UC starting IFX with a Pediatric Ulcerative Colitis Activity Index (PUCAI) ≥35 and with available post-induction TL were recruited. UC characteristics, IFX dosage and interval, primary non-response, IFX failure, and surgery after 24 months were collected. Post induction TL, anti-IFX antibodies, and laboratory evaluations at the time of starting IFX were also acquired. RESULTS A total of 90 children were enrolled, of whom 39 (43.3%) were classified as severe UC and 51 (56.6%) as moderate UC. Median post-induction IFX TL were lower in severe UC versus moderate group (5.5 vs 10.3; p = 0.03), despite a more frequently intensified IFX regimen. Children in the higher TL quartiles showed increased rates of clinical, biological, and combined remission (p = 0.04, p < 0.001, and p = 0.01, respectively). In a multivariate analysis, a PUCAI ≥65 and time interval from last IFX infusion were the only predictors associated with IFX TL. At 24 months, children in the higher TL quartiles had a decreased risk of IFX failure (p = 0.002). The severe UC group showed a higher risk of IFX failure at 24 months (16/23 (41%) vs. 11/40 (21.6%); p = 0.05). Kaplan-Meier methods demonstrated a trend toward statistical significance, with a two-year cumulative colectomy rate of 15.38% (95% confidence interval (CI) 8.1-15.6%) in children with severe UC and 3.92% (95% CI 2.9-10.8%) in patients with moderate UC (logrank test p = 0.06). CONCLUSIONS Children starting IFX with severe UC showed lower post-induction TL and poor disease outcomes. Achieving adequate TL was associated with better efficacy outcomes.
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Affiliation(s)
- Hillary Moore
- Gastroenterology, Hepatology and Nutrition Division, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Pasquale Dolce
- Department of Public Health, University of Naples 'Federico II', Naples, Italy
| | - Nina Devas
- Gastroenterology, Hepatology and Nutrition Division, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Robert Baldassano
- Gastroenterology, Hepatology and Nutrition Division, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Massimo Martinelli
- Gastroenterology, Hepatology and Nutrition Division, The Children's Hospital of Philadelphia, Philadelphia, USA.,Department of Translational Medical Science, Section of Pediatrics, University of Naples 'Federico II', Naples, Italy
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Szemes K, Soós A, Hegyi P, Farkas N, Erős A, Erőss B, Mezősi E, Szakács Z, Márta K, Sarlós P. Comparable Long-Term Outcomes of Cyclosporine and Infliximab in Patients With Steroid-Refractory Acute Severe Ulcerative Colitis: A Meta-Analysis. Front Med (Lausanne) 2020; 6:338. [PMID: 32039218 PMCID: PMC6985460 DOI: 10.3389/fmed.2019.00338] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 12/23/2019] [Indexed: 12/28/2022] Open
Abstract
Background: In steroid-refractory acute severe ulcerative colitis (ASUC), cyclosporine (CYS) or infliximab (IFX) may be considered as a second-line alternative to avoid colectomy. There are short-term data reported, but until now, there is no meta-analysis regarding long-term outcomes of CYS and IFX in patients with ASUC. Aim: To compare long-term efficacy and safety of CYS and IFX in a meta-analysis. Methods: Three electronic databases (PubMed, Embase, Cochrane Central Register of Controlled Trials) were searched for studies which compared CYS vs. IFX in adults with ASUC. Long-term colectomy-free rate from 1 to 10 years during CYS or IFX therapy was collected, last updated up to 22nd May 2019. Primary outcome was long-term colectomy-free rate, secondary outcomes were adverse events (AE), serious adverse events (SAE), and mortality. Long-term colectomy-free survival and safety measures were pooled with the random-effect model. Odds ratios (OR) with 95% confidence intervals (CI) were calculated. Results: Data from 1,607 patients in 15 trials were extracted. In the first 3 years, pooled OR for colectomy-free survival was higher with IFX than with CYS (OR = 1.59, 95% CI: 1.11–2.29, p = 0.012; OR = 1.57, 95% CI: 1.14–2.18, p = 0.006; and OR = 1.75, 95% CI: 1.08–2.84, p = 0.024; at 1, 2, and 3 years, respectively). However, the significant difference remained undetected from the fourth year of follow-up and in subgroup of RCTs (OR = 1.35, 95% CI: 0.90–2.01, p = 0.143; OR = 1.41, 95% CI: 0.94–2.12, p = 0.096; and OR = 1.34, 95% CI: 0.89–2.00, p = 0.157; at 1, 2, and 3 years, respectively). No significant difference was detected regarding adverse events, serious adverse events and mortality between the groups. The neutral associations proved to be underpowered with trial sequential analysis. Conclusion: However observational studies show IFX as a better choice, according to the RCTs, choosing either CYS or IFX as rescue therapy for ASUC, the long-term outcomes are not different, although further large RCTs are warranted.
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Affiliation(s)
- Kata Szemes
- First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Alexandra Soós
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
| | - Péter Hegyi
- First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary.,Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,János Szentágothai Research Centre, University of Pécs, Pécs, Hungary.,Momentum Gastroenterology Multidisciplinary Research Group, Hungarian Academy of Sciences, University of Szeged, Szeged, Hungary
| | - Nelli Farkas
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Institute of Bioanalysis, Medical School, University of Pécs, Pécs, Hungary
| | - Adrienn Erős
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Bálint Erőss
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Emese Mezősi
- First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Zsolt Szakács
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,János Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Katalin Márta
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,János Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Patrícia Sarlós
- First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary.,János Szentágothai Research Centre, University of Pécs, Pécs, Hungary
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Affiliation(s)
- David Laharie
- Service d'Hépato-Gastroentérologie, Hôpital Haut-Lévêque, CHU de Bordeaux, Pessac, France
| | - Pauline Rivière
- Service d'Hépato-Gastroentérologie, Hôpital Haut-Lévêque, CHU de Bordeaux, Pessac, France
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Verdon C, Bessissow T, Lakatos PL. Management of Acute Severe Colitis in the Era of Biologicals and Small Molecules. J Clin Med 2019; 8:jcm8122169. [PMID: 31817972 PMCID: PMC6947608 DOI: 10.3390/jcm8122169] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 12/02/2019] [Accepted: 12/06/2019] [Indexed: 12/14/2022] Open
Abstract
Acute severe ulcerative colitis (ASUC) is a medical emergency which occurs in about 20%–30% of patients with ulcerative colitis during their lifetime, and does carry a mortality risk of 1%. The management of inflammatory bowel diseases has evolved with changes in objective patient monitoring, as well as the availability of new treatment options with the development of new biological and small molecules; however, data is limited regarding their use in the context of ASUC. This review aims to discuss the emerging data regarding biologicals and small molecules therapies in the context of ASUC.
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Affiliation(s)
- Christine Verdon
- Division of Gastroenterology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada; (C.V.); (T.B.)
- Department of Gastroenterology, Campbelltown Hospital, Sydney, NSW 2560, Australia
| | - Talat Bessissow
- Division of Gastroenterology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada; (C.V.); (T.B.)
| | - Peter L. Lakatos
- Division of Gastroenterology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada; (C.V.); (T.B.)
- 1st Department of Medicine, Semmelweis University, Budapest H1083, Hungary
- Correspondence: ; Tel.: +514-934-1934 (ext. 45567)
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Affiliation(s)
- Victor G Chedid
- Gastroenterology and Hepatology Division, Mayo Clinic, Rochester, Minnesota
| | - Sunanda V Kane
- Gastroenterology and Hepatology Division, Mayo Clinic, Rochester, Minnesota
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Sebastian S, Kennedy NA, Subramanian S, Raine T. Editorial: accelerated infliximab induction-it's time to settle the debate! Authors' reply. Aliment Pharmacol Ther 2019; 50:1061-1062. [PMID: 31625193 DOI: 10.1111/apt.15498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Shaji Sebastian
- IBD Unit, Department of Gastroenterology, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Nicholas A Kennedy
- Department of Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | | | - Tim Raine
- Addenbrooke's Hospital, Cambridge, UK
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