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Alsoud D, Moes DJAR, Wang Z, Soenen R, Layegh Z, Barclay M, Mizuno T, Minichmayr IK, Keizer RJ, Wicha SG, Wolbink G, Lambert J, Vermeire S, de Vries A, Papamichael K, Padullés-Zamora N, Dreesen E. Best Practice for Therapeutic Drug Monitoring of Infliximab: Position Statement from the International Association of Therapeutic Drug Monitoring and Clinical Toxicology. Ther Drug Monit 2024; 46:291-308. [PMID: 38648666 DOI: 10.1097/ftd.0000000000001204] [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] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 02/21/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Infliximab, an anti-tumor necrosis factor monoclonal antibody, has revolutionized the pharmacological management of immune-mediated inflammatory diseases (IMIDs). This position statement critically reviews and examines existing data on therapeutic drug monitoring (TDM) of infliximab in patients with IMIDs. It provides a practical guide on implementing TDM in current clinical practices and outlines priority areas for future research. METHODS The endorsing TDM of Biologics and Pharmacometrics Committees of the International Association of TDM and Clinical Toxicology collaborated to create this position statement. RESULTS Accumulating data support the evidence for TDM of infliximab in the treatment of inflammatory bowel diseases, with limited investigation in other IMIDs. A universal approach to TDM may not fully realize the benefits of improving therapeutic outcomes. Patients at risk for increased infliximab clearance, particularly with a proactive strategy, stand to gain the most from TDM. Personalized exposure targets based on therapeutic goals, patient phenotype, and infliximab administration route are recommended. Rapid assays and home sampling strategies offer flexibility for point-of-care TDM. Ongoing studies on model-informed precision dosing in inflammatory bowel disease will help assess the additional value of precision dosing software tools. Patient education and empowerment, and electronic health record-integrated TDM solutions will facilitate routine TDM implementation. Although optimization of therapeutic effectiveness is a primary focus, the cost-reducing potential of TDM also merits consideration. CONCLUSIONS Successful implementation of TDM for infliximab necessitates interdisciplinary collaboration among clinicians, hospital pharmacists, and (quantitative) clinical pharmacologists to ensure an efficient research trajectory.
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Affiliation(s)
- Dahham Alsoud
- Translational Research in Gastrointestinal Disorders, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Dirk Jan A R Moes
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Zhigang Wang
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Rani Soenen
- Dermatology Research Unit, Ghent University, Ghent, Belgium
- Department of Dermatology, Ghent University Hospital, Ghent, Belgium
| | - Zohra Layegh
- Department of Pathology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Murray Barclay
- Departments of Gastroenterology and Clinical Pharmacology, Christchurch Hospital, Te Whatu Ora Waitaha and University of Otago, Christchurch, New Zealand
| | - Tomoyuki Mizuno
- Division of Translational and Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Iris K Minichmayr
- Department of Clinical Pharmacology, Medical University Vienna, Vienna, Austria
| | | | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Gertjan Wolbink
- Department of Rheumatology, Amsterdam Rheumatology and Immunology Center Location Reade, Amsterdam, Netherlands
- Sanquin Research and Landsteiner Laboratory, Department of Immunopathology, Amsterdam UMC, Amsterdam, Netherlands
| | - Jo Lambert
- Dermatology Research Unit, Ghent University, Ghent, Belgium
- Department of Dermatology, Ghent University Hospital, Ghent, Belgium
| | - Séverine Vermeire
- Translational Research in Gastrointestinal Disorders, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Annick de Vries
- Sanquin Diagnostic Services, Pharma & Biotech Services, Amsterdam, the Netherlands
| | - Konstantinos Papamichael
- Center for Inflammatory Bowel Diseases, Division of Gastroenterology, Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Núria Padullés-Zamora
- Department of Pharmacy, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain; and
- School of Pharmacy, University of Barcelona, Barcelona, Spain
| | - Erwin Dreesen
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
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McDonald C, Kerr H, Gibbons E, Lukose T, Cheriyan D, Harewood G, Patchett S, O’Toole A, Kelly O, Boland K. Higher Ustekinumab Levels in Maintenance Therapy are Associated with Greater Mucosal Healing and Mucosal Response in Crohn's Disease: An Experience of 2 IBD Centers. Inflamm Bowel Dis 2024; 30:423-428. [PMID: 37158577 PMCID: PMC10906356 DOI: 10.1093/ibd/izad073] [Citation(s) in RCA: 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: 08/22/2022] [Indexed: 05/10/2023]
Abstract
BACKGROUND Ustekinumab (UST), a human monoclonal antibody that binds the p40 subunit of interleukin 12 (IL-12) and IL-23, is licensed for induction and maintenance therapy of moderate to severe inflammatory bowel disease (IBD). To date, there is limited data published on any potential association between ustekinumab serum trough levels and mucosal healing in order to guide treatment strategies and appropriate dosing. AIM This study aims to identify a relationship between maintenance ustekinumab serum trough levels and mucosal healing and/or response in patients with Crohn's disease in an observational cohort study. METHODS Ustekinumab serum trough levels and antibody titres were analyzed in patients on maintenance drug using an ELISA drug-tolerant assay. Mucosal response (MR) was defined as ≥50% reduction in fecal calprotectin level (FC) and/or ≥50% reduction in the Simple Endoscopic Score for Crohn's Disease (SES-CD score). Mucosal healing (MH) was defined as FC ≤150 µg/mL and/or global SES-CD score ≤5. Median trough levels were analyzed using the Kruskal-Wallis test, and logistic regression was used to determine sensitivity and specificity of levels predicting mucosal response. RESULTS Forty-seven patients on maintenance ustekinumab for Crohn's disease were included in this study. The majority were female (66%), with a median age of 40 years (21-78 years). The majority of patients were biologic-experienced (89.4%, n = 42). Patients with histologically confirmed Crohn's disease represented 100% (n = 47) of the cohort. Over one-third of patients (n = 18, 38.3%) were on higher than standard dosing of 90 mg every 8 weeks. Patients with mucosal healing (n = 30) had significantly higher mean serum ustekinumab levels (5.7 µg/mL, SD 6.4) compared with those with no response (1.1 µg/mL, SD 0.52; n = 7, P < .0001). A serum ustekinumab trough level greater than 2.3 µg/mL was associated with MH, with a sensitivity of 100% and specificity of 90.6% (likelihood ratio 10.7). Similarly, for patients with MR (n = 40), we observed a higher mean serum ustekinumab trough level (5.1 µg/mL, SD 6.1) compared with those with no response (1.1 µg/mL, SD 0.52; n = 7, P < .0001). Furthermore, a serum ustekinumab trough level greater than 2.3 µg/mL was associated with a 10-fold increased likelihood of mucosal response vs mucosal nonresponse (sensitivity 100%, specificity 90.5%, likelihood ratio 10.5). CONCLUSION This study demonstrates that higher ustekinumab serum trough levels are associated with a greater likelihood of achieving mucosal healing and mucosal response in patients with Crohn's disease regardless of prior biologic exposure. Further prospective studies are required to correlate target maintenance trough levels and the optimal time to dose-escalate in order to improve patient outcomes.
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Affiliation(s)
- Ciarán McDonald
- Department of Gastroenterology, Beaumont Hospital, RCSI Hospital Group, Dublin 9, Ireland
| | - Hilary Kerr
- Department of Gastroenterology, James Connolly Hospital, RCSI Hospital Group, Dublin 15, Ireland
| | - Eimear Gibbons
- Department of Gastroenterology, James Connolly Hospital, RCSI Hospital Group, Dublin 15, Ireland
| | - Tincymol Lukose
- Department of Gastroenterology, Beaumont Hospital, RCSI Hospital Group, Dublin 9, Ireland
| | - Danny Cheriyan
- Department of Gastroenterology, Beaumont Hospital, RCSI Hospital Group, Dublin 9, Ireland
| | - Gavin Harewood
- Department of Gastroenterology, Beaumont Hospital, RCSI Hospital Group, Dublin 9, Ireland
| | - Stephen Patchett
- Department of Gastroenterology, Beaumont Hospital, RCSI Hospital Group, Dublin 9, Ireland
| | - Aoibhlinn O’Toole
- Department of Gastroenterology, Beaumont Hospital, RCSI Hospital Group, Dublin 9, Ireland
| | - Orlaith Kelly
- Department of Gastroenterology, James Connolly Hospital, RCSI Hospital Group, Dublin 15, Ireland
| | - Karen Boland
- Department of Gastroenterology, Beaumont Hospital, RCSI Hospital Group, Dublin 9, Ireland
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Faye AS, Lee KE, Hudesman D, Dervieux T. Older Adults With Inflammatory Bowel Disease Are at Higher Risk of Developing Antibodies to Infliximab. Inflamm Bowel Dis 2024:izad305. [PMID: 38170900 DOI: 10.1093/ibd/izad305] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Indexed: 01/05/2024]
Abstract
Lay Summary
Although older age is thought to confer immunosenescence, we found that older adults with inflammatory bowel disease are independently at higher risk to develop antibodies to infliximab. Additionally, older adults are less likely to receive escalated doses of infliximab.
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Affiliation(s)
- Adam S Faye
- Division of Gastroenterology, NYU Grossman School of Medicine, New York, NY, USA
| | - Kate E Lee
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - David Hudesman
- Division of Gastroenterology, NYU Grossman School of Medicine, New York, NY, USA
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van Hoeve K, Thomas D, Hillary T, Hoffman I, Dreesen E. Identifying risk factors of anti-TNF induced skin lesions and other adverse events in paediatric patients with inflammatory bowel disease. J Pediatr Gastroenterol Nutr 2024; 78:95-104. [PMID: 38291690 DOI: 10.1002/jpn3.12066] [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: 06/02/2023] [Revised: 10/27/2023] [Accepted: 11/02/2023] [Indexed: 02/01/2024]
Abstract
OBJECTIVES While higher infliximab (IFX) trough concentrations (TCs) are associated with better outcomes in patients with inflammatory bowel disease (IBD), they could pose a risk for adverse events (AEs), including IFX-induced skin lesions. Therefore, we studied correlations between IFX TCs and occurrence of AEs in paediatric IBD patients. METHODS In this single-centre study, all children with Crohn's disease (CD) and ulcerative colitis (UC) receiving IFX maintenance therapy who underwent proactive drug monitoring between March 2015 and August 2022 were included. IFX doses/intervals/TCs and patient characteristics were systematically registered, as well as AEs and skin lesions appearance. RESULTS A total of 109 patients (72 CD and 37 UC) contributed 2913 IFX TCs. During a median follow-up of 3.0 [1.5-4.5] years, we observed 684 AEs in 101 patients and 49 skin lesions in 35 patients. There was no significant difference (p = .467) in median TCs between patients with and without skin lesions. However, higher median IFX doses were associated with an increased hazard rate of skin lesions [HR 1.084 (1.024-1.148), p = .005], in addition to female sex [2.210 (1.187-5.310), p = .016] and diagnosis of CD [1.695 (1.241-1.877), p = .011]. Considering IFX therapeutic TC cut-offs of 5.0 and 9.0 µg/mL, there was no significant difference in AE rate (p = .749 and p = .833, respectively). Also, no significant association between IFX doses and AE rate (p = .159). CONCLUSIONS Increasing the IFX dose to achieve therapeutic TCs may not increase the overall risk of AEs in paediatric IBD patients. However, concerns arise regarding the risk of skin lesions, especially in female CD patients.
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Affiliation(s)
- Karen van Hoeve
- Department of Paediatric gastroenterology & Hepatology & Nutrition, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Debby Thomas
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Tom Hillary
- Department of Dermatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Ilse Hoffman
- Department of Paediatric gastroenterology & Hepatology & Nutrition, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Erwin Dreesen
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
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Gazelakis K, Chu I, Martin C, Sparrow MP. Infections in inflammatory bowel disease patients on immunomodulator and biologic therapy are not associated with high serum drug levels. Intern Med J 2024; 54:139-148. [PMID: 37151186 DOI: 10.1111/imj.16105] [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: 05/31/2022] [Accepted: 05/04/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) therapies now utilise higher doses of immunomodulatory and biologic therapies, predisposing patients to an increased risk of infections. AIMS We aimed to determine whether infections were associated with high anti-tumour necrosis factor (TNF) drug levels in IBD and to quantify the risk and consequences of infections. METHODS Two retrospective studies were performed, a descriptive cohort study and a matched case-control study. For the matched case-control study, cases of infection occurring on anti-TNF agents were matched in a 1:2 ratio to controls of anti-TNF treated patients without infections. RESULTS In the descriptive study, 76 infections occurred in 60 patients, including 49 bacterial, 24 viral, four fungal and four parasitic. Of these, 61 (80.3%) were on biologics, 49 (64.5%) on immunomodulators and 11 (14.5%) on corticosteroids. Thirty-four (44.7%) were on combination therapy, 27 (35.5%) on biologic monotherapy and 15 (19.7%) on immunomodulator monotherapy. Median anti-TNF drug levels in infection cases were 3.9 μg/mL for infliximab and 6.0 μg/mL for adalimumab. In the case-control study, 32 cases of infection in 27 anti-TNF treated patients were matched with 64 anti-TNF treated controls without infections. Among infection cases, 59.5% were on combination therapy versus 40.6% on biologic monotherapy (P = 0.59). Median drug levels for cases and controls respectively were 3.9 μg/mL versus 5.5 μg/mL for infliximab (P = 0.72) and 6.0 μg/mL versus 9.9 μg/mL for adalimumab (P = 0.34). CONCLUSION Infections in patients with IBD were common, and the risk was highest with combination therapy. Infections were not associated with high serum anti-TNF levels.
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Affiliation(s)
- Kathryn Gazelakis
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne, Victoria, Australia
| | - Isabel Chu
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne, Victoria, Australia
| | - Catherine Martin
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
- Data Science and AI Platform, Monash e-Research Centre, Melbourne, Victoria, Australia
| | - Miles P Sparrow
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne, Victoria, Australia
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Fuentes-Valenzuela E, García-Alonso FJ, Maroto-Martín C, Juan Casamayor L, Garrote JA, Almendros Muñoz R, De Prado Á, Vara Castrodeza A, Marinero MÁ, Calleja Carbajosa R, Barrio J. Influence of HLADQA1*05 Genotype in Adults With Inflammatory Bowel Disease and Anti-TNF Treatment With Proactive Therapeutic Drug Monitoring: A Retrospective Cohort Study. Inflamm Bowel Dis 2023; 29:1586-1593. [PMID: 36617284 DOI: 10.1093/ibd/izac259] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Carriers of the human leucocyte antigen variant HLADQA1*05 (rs2097432) are at risk of developing antibodies against infliximab and adalimumab with reduced tumor necrosis factor (TNF) antagonist persistence. The impact of proactive therapeutic drug monitoring (PTDM) on this association has been barely assessed. METHODS We conducted a retrospective single-center cohort study including patients with inflammatory bowel disease starting anti-TNF therapy between January 2017 and March 2021. Proactive therapeutic drug monitoring was defined as periodic drug level measurement (≥2 determinations during the first year of treatment and ≥1/annual determination during the following years), regardless of clinical condition, followed by dose optimization. Variables associated with treatment persistence were assessed with multivariable Cox regression analysis. RESULTS A total of 112 patients were included, 52 (46.4%) HLA-DQA1*05 carriers, with a median follow-up of 73.9 (interquartile range, 35.4-133.1) weeks. Combination therapy with thiopurines was more frequent among HLA-DQA1*05 noncarriers (28 [46.7%] vs 12 [23.1%]; P = .01). Clinical remission rates at week 14 (77.9% vs 73.9%; P = .69) and 56 (73.2% vs 68.4%; P = .64) were similar between HLA-DQA1*05 noncarriers and carriers. Drug persistence was higher among HLA-DQA1*05 carriers (hazard ratio [HR], 0.32; 95% confidence interval, 0.14-0.71; P = .01). Multivariable Cox regression analysis identified systemic steroids at anti-TNF initiation (HR, 4; 95% confidence interval, 1.7-9.7) as a risk factor and HLA-DQA1*05 carriers (HR, 0.31; 95% confidence interval, 0.12-0.81) as a protective factor of treatment cessation. CONCLUSION In adult patients with PTDM, a positive HLA-DQA1*05 genotype does not associate a higher risk of treatment cessation nor worse clinical outcomes.
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Affiliation(s)
- Esteban Fuentes-Valenzuela
- Gastroenterology Department, Hospital Universitario Rio Hortega, Valladolid, St. Dulzaina, 2, 47012 Valladolid, Spain
| | | | - Carlos Maroto-Martín
- Gastroenterology Department, Hospital Universitario Rio Hortega, Valladolid, St. Dulzaina, 2, 47012 Valladolid, Spain
| | - Laura Juan Casamayor
- Gastroenterology Department, Hospital Universitario Rio Hortega, Valladolid, St. Dulzaina, 2, 47012 Valladolid, Spain
| | - José Antonio Garrote
- Department of Laboratory Medicine, Hospital Universitario Rio Hortega, Valladolid, St. Dulzaina, 2, 47012 Valladolid, Spain
| | - Rosendo Almendros Muñoz
- Department of Pharmacy, Hospital Universitario Rio Hortega, Valladolid, St. Dulzaina, 2, 47012 Valladolid, Spain
| | - Ángel De Prado
- Gastroenterology Department, Hospital Universitario Rio Hortega, Valladolid, St. Dulzaina, 2, 47012 Valladolid, Spain
| | - Alejando Vara Castrodeza
- Radiology Department. Hospital Universitario Rio Hortega, Valladolid, St. Dulzaina, 2, 47012 Valladolid, Spain
| | - María Ángeles Marinero
- Gastroenterology Department, Hospital Universitario Rio Hortega, Valladolid, St. Dulzaina, 2, 47012 Valladolid, Spain
| | - Raquel Calleja Carbajosa
- Gastroenterology Department, Hospital Universitario Rio Hortega, Valladolid, St. Dulzaina, 2, 47012 Valladolid, Spain
| | - Jesús Barrio
- Gastroenterology Department, Hospital Universitario Rio Hortega, Valladolid, St. Dulzaina, 2, 47012 Valladolid, Spain
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Gibson M, Subedi S, Barker DH, Masur S, Mallette MM, Lingannan A, Recinos Soto AA, Esharif D, Maxwell SH, Riaz MS, Herzlinger MI, Shalon LB, Cerezo CS, Kasper VL, Ross AM, Leleiko NS, Shapiro JM. Safety and Durability of Accelerated Infliximab Dosing Strategies in Pediatric IBD: A Single Center, Retrospective Study. J Pediatr Gastroenterol Nutr 2023; 77:207-213. [PMID: 37084343 DOI: 10.1097/mpg.0000000000003794] [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: 04/23/2023]
Abstract
OBJECTIVES Infliximab (IFX) is commonly used to treat children with inflammatory bowel disease (IBD). We previously reported that patients with extensive disease started on IFX at a dose of 10 mg/kg had greater treatment durability at year one. The aim of this follow-up study is to assess the long-term safety and durability of this dosing strategy in pediatric IBD. METHODS We performed a retrospective single-center study of pediatric IBD patients started on IFX over a 10-year period. RESULTS Two hundred ninety-one patients were included (mean age = 12.61, 38% female) with a follow-up range of 0.1-9.7 years from IFX induction. One hundred fifty-five (53%) were started at a dose of 10 mg/kg. Only 35 patients (12%) discontinued IFX. The median duration of treatment was 2.9 years. Patients with ulcerative colitis ( P ≤ 0.01) and patients with extensive disease ( P = 0.01) had lower durability, despite a higher starting dose of IFX ( P = 0.03). Adverse events (AEs) were observed to occur at a rate of 234 per 1000 patient-years. Patients with a higher serum IFX trough level (≥20 µg/mL) had a higher rate of AEs ( P = 0.01). Use of combination therapy had no impact on risk of AEs ( P = 0.78). CONCLUSIONS We observed an excellent IFX treatment durability, with only 12% of patients discontinuing therapy over the observed timeframe. The overall rate of AEs was low, the majority being infusion reactions and dermatologic conditions. Higher IFX dose and serum trough level> 20 µg/mL were associated with higher risk of AEs, the majority being mild and not resulting in cessation of therapy.
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Affiliation(s)
- Meghan Gibson
- From Warren Alpert Medical School of Brown University, Providence, RI
- the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Hasbro Children's Hospital, Providence, RI
| | - Shova Subedi
- From Warren Alpert Medical School of Brown University, Providence, RI
- the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Hasbro Children's Hospital, Providence, RI
| | - David H Barker
- the Department of Child and Adolescent Psychiatry, Rhode Island Hospital, Providence, RI
| | - Samuel Masur
- the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Hasbro Children's Hospital, Providence, RI
- the Department of Pediatrics, Hasbro Children's Hospital, Providence, RI
| | | | - Archana Lingannan
- From Warren Alpert Medical School of Brown University, Providence, RI
- the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Hasbro Children's Hospital, Providence, RI
| | - Aldo Alejandro Recinos Soto
- From Warren Alpert Medical School of Brown University, Providence, RI
- the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Hasbro Children's Hospital, Providence, RI
| | - Dyadin Esharif
- From Warren Alpert Medical School of Brown University, Providence, RI
- the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Hasbro Children's Hospital, Providence, RI
| | - Sarah H Maxwell
- the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Hasbro Children's Hospital, Providence, RI
- the Department of Pediatrics, Hasbro Children's Hospital, Providence, RI
| | - Muhammad Safwan Riaz
- From Warren Alpert Medical School of Brown University, Providence, RI
- the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Hasbro Children's Hospital, Providence, RI
| | - Michael I Herzlinger
- From Warren Alpert Medical School of Brown University, Providence, RI
- the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Hasbro Children's Hospital, Providence, RI
| | - Linda B Shalon
- From Warren Alpert Medical School of Brown University, Providence, RI
- the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Hasbro Children's Hospital, Providence, RI
| | - Carolina S Cerezo
- From Warren Alpert Medical School of Brown University, Providence, RI
- the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Hasbro Children's Hospital, Providence, RI
| | - Vania L Kasper
- From Warren Alpert Medical School of Brown University, Providence, RI
- the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Hasbro Children's Hospital, Providence, RI
| | - Albert M Ross
- From Warren Alpert Medical School of Brown University, Providence, RI
- the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Hasbro Children's Hospital, Providence, RI
| | - Neal S Leleiko
- the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Irving Medical Center, New York, NY
| | - Jason M Shapiro
- From Warren Alpert Medical School of Brown University, Providence, RI
- the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Hasbro Children's Hospital, Providence, RI
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Bhattacharya A, Travis D, Osterman MT, Lewis JD, Bhagya Rao B, Lee H, Lichtenstein GR. Supratherapeutic Infliximab Levels Do Not Predict Risk of Short-term Complications in Adults With Crohn's Disease. J Clin Gastroenterol 2023; 57:66-73. [PMID: 34907922 DOI: 10.1097/MCG.0000000000001637] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 10/10/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND It is uncertain if higher infliximab trough levels (TLs) confer a greater risk of infectious/noninfectious complications (IC/NIC). We aimed to assess the risk of IC and NIC in patients with different TLs. METHODS We retrospectively evaluated a cohort of Crohn's disease (CD) patients treated with infliximab who underwent therapeutic drug monitoring (TDM), at a tertiary inflammatory bowel disease center, between January 1, 2010, and December 1, 2019. TDM was defined as checking of infliximab trough and antibody levels within a 48-hour period before administration. Patients with a minimum of 3-month assessment pre-TDM and post-TDM were included. In the case of multiple TDMs, the highest TL was considered, and patients were distributed across 4 predefined TL groups (A: <5 µg/mL, B: 5 to 10 µg/mL, C: 10 to 15 µg/mL, and D: ≥15 µg/mL). Rates of IC and NIC during the 3-month prior and following TDM were compared across the groups. In addition, duration of exposure, in terms of months up to TDM, was collected to analyze differences in rates of IC and NIC. RESULTS Our study included 341 CD patients (median age: 35 y, 58% men). IC and NIC occurred in 52 (15%) and 30 (9%) patients, respectively. Rates of IC and NIC were similar across the 4 TL groups ( P =0.9 and 0.7, respectively for IC and NIC). On multivariable analysis, exposure to infliximab >40 months (as determined by receiver operating characteristic curve analysis) was associated with decreased odds for IC (adjusted odds ratio=0.51, P =0.04), but not NIC (adjusted odds ratio=0.72, P =0.46). CONCLUSIONS In this large CD cohort, there was no association between infliximab TL and risk of short-term IC or NIC. Interestingly, a shorter duration of exposure predicted higher rates of IC. This supports the safety of targeting higher infliximab TLs when necessary and greater vigilance during the early stages of treatment.
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Légeret C, Furlano R, Köhler H. Therapy Strategies for Children Suffering from Inflammatory Bowel Disease (IBD)—A Narrative Review. Children 2022; 9:617. [PMID: 35626795 PMCID: PMC9140197 DOI: 10.3390/children9050617] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/19/2022] [Accepted: 04/22/2022] [Indexed: 11/30/2022]
Abstract
The incidence of inflammatory bowel disease (IBD) is increasing, and more children at a younger age are affected. The pathogenesis seems to be an interaction of microbial factors, a sensitivity of the immune system, and the intestinal barrier, leading to an inappropriate immune response. Not only has the role of biological agents become more important in the last decade in the treatment of children and adolescents, but also new insights into the composition of the gastrointestinal microbiome and personal diet implications have increased our understanding of the disease and opened up potential therapeutic pathways. This narrative review provides an overview of current recommendations, therapeutic options, drug monitoring, and practical guidelines for paediatricians involved with paediatric IBD patients. Furthermore, the off-label use of potential helpful drugs in the treatment of these patients is discussed.
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Sirmai L, Pelletier AL, Gault N, Zallot C, Bouguen G, Bouchard D, Roland Nicaise P, Peyneau M, Sironneau S, Bittencourt MDC, Petitcollin A, Fernandez P, Roblin X, Siproudhis L, Abramowitz L. Relationship between clinical remission of perianal fistulas in Crohn’s disease and serum adalimumab concentrations: A multi-center cross-sectional study. World J Gastroenterol 2022; 28:961-972. [PMID: 35317057 PMCID: PMC8908286 DOI: 10.3748/wjg.v28.i9.961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/25/2021] [Accepted: 01/29/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Crohn’s disease (CD) is complicated by perianal fistulas in approximately 20% of patients. Achieving permanent fistula closure remains a challenge for physicians. An association between serum anti-tumor necrosis factor-α concentrations and clinical outcomes in patients with CD has been demonstrated; however, little information is available on serum adalimumab (ADA) concentrations and remission of perianal fistulas in such patients.
AIM To study the relationship between serum ADA concentrations and clinical remission of CD-associated perianal fistulas.
METHODS This cross-sectional study of patients with CD-associated perianal fistulas treated with ADA was performed at four French hospitals between December 2013 and March 2018. At the time of each serum ADA concentration measurement, we collected information about the patients and their fistulas. The primary study endpoint was clinical remission of fistulas defined as the absence of drainage (in accordance with Present’s criteria), with a PDAI ≤ 4, absence of a seton and assessment of the overall evaluation as favorable by the proctologist at the relevant center. We also assessed fistula healing [defined as being in clinical and radiological (magnetic resonance imaging, MRI) remission] and adverse events.
RESULTS The study cohort comprised 34 patients who underwent 56 evaluations (patients had between one and four evaluations). Fifteen patients had clinical remissions (44%), four of whom had healed fistulas on MRI. Serum ADA concentrations were significantly higher at evaluations in which clinical remission was identified than at evaluations in which it was not [14 (10-16) vs 10 (2-15) μg/mL, P = 0.01]. Serum ADA concentrations were comparable at the times of evaluation of patients with and without healed fistulas [11 (7-14) vs 10 (4-16) μg/mL, P = 0.69]. The adverse event rate did not differ between different serum ADA concentrations.
CONCLUSION We found a significant association between high serum ADA concentrations and clinical remission of CD-associated perianal fistulas.
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Affiliation(s)
- Laura Sirmai
- Division of Hepato-Gastroenterology and Digestive Oncology, Bichat Claude Bernard University Hospital, Paris 75018, France
- Division of Hepato-Gastroenterology, Hospital Croix Saint Simon, Paris 75020, France
| | - Anne-Laure Pelletier
- Division of Hepato-Gastroenterology and Digestive Oncology, Bichat Claude Bernard University Hospital, Paris 75018, France
| | - Nathalie Gault
- Division of Epidemiology, Biostatistics and Clinical Research, University Hospital Center Bichat, Paris 75018, France
- National Institute of Health and Medical Research CIC-EC1425, University Hospital Center Bichat, Paris 75018, France
| | - Camille Zallot
- Division of Gastroenterology, Nancy Regional and University Hospital Center, Nancy 54035, France
| | - Guillaume Bouguen
- Imphy CIC 1414 Group and Division of Gastroenterology and Hepatology, University Hospital of Rennes, Pontchaillou, Rennes 35033, France
| | | | | | - Marine Peyneau
- Division of Immunology, University Hospital Center Bichat, Paris 75018, France
- Inflammation, Microbiome and Immunosurveillance, Faculty of Pharmacy, Université Paris-Saclay, Châtenay-Malabry 92290, France
| | | | - Marcelo De Carvalho Bittencourt
- Division of Immunology, Nancy Regional and University Hospital Center, Nancy 54000, France
- University of Lorraine, CNRS UMR 7365, IMoPA, Nancy 54000, France
| | - Antoine Petitcollin
- Department of Clinical and Biological Pharmacology and Pharmacovigilance, Pharmacoepidemiology and Drug Information Center, Rennes University Hospital, Rennes 35700, France
| | - Pedro Fernandez
- Division of Radiology, University Hospital Center Bichat, Paris 75018, France
- Orangerie Center, Le Perreux-sur-Marne 94170, France
| | - Xavier Roblin
- Division of Gastroenterology, CHU Saint Etienne, Saint-Priest-en-Jarez 42270, France
| | - Laurent Siproudhis
- Imphy CIC 1414 Group and Division of Gastroenterology and Hepatology, University Hospital of Rennes, Pontchaillou, Rennes 35033, France
| | - Laurent Abramowitz
- Division of Gastroenterology and Hepatology and Proctology, University Hospital Center Bichat, Paris 75018, France
- Ramsay GDS Clinique Blomet, Paris 75018, France
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11
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Theodoraki E, Orfanoudaki E, Foteinogiannopoulou K, Andreou NP, Gazouli M, Koutroubakis IE. Effect of antinuclear antibodies on pharmacokinetics of anti-TNF therapy in patients with inflammatory bowel disease. Int J Colorectal Dis 2022; 37:639-646. [PMID: 35013823 DOI: 10.1007/s00384-021-04091-6] [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] [Accepted: 12/28/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE The detection of antinuclear antibodies (ANA) in serum of patients with inflammatory bowel disease (IBD) has been associated with a worse response to anti-TNF therapy and the development of cutaneous or arthritic manifestations. The aim of this study was to investigate a possible association of serum ANA with infliximab (IFX) and adalimumab (ADA) trough levels (TLs) and anti-drug antibodies in IBD patients treated with IFX or ADA. METHODS Consecutive IBD patients under maintenance therapy with IFX or ADA in whom there was at least one available measurement of anti-TNF TLs, antibodies to IFX or ADA, and ANA in serum were included. The correlation of ANA positivity with demographics, clinical characteristics, treatment, TLs and anti-drug antibodies, of all patients was analyzed. RESULTS One hundred two IBD patients under maintenance therapy with IFX or ADA were enrolled. Of these, 53 (52%) were ANA positive with 28 (27.5%) positive also to anti-ds-DNA in serum. In the univariate analysis ANA positivity was found to be correlated with age (P = 0.008), female gender (P = 0.03), duration of treatment (P = 0.06), arthralgias (P = 0.04) and TLs (P = 0.005). However, in multivariate logistic regression analysis only age and TLs remained significantly associated with the presence of ANA positivity (P = 0.04 and P = = 0.006, respectively). No significant association of ANA positivity with the development of cutaneous or rheumatological manifestations was found. CONCLUSIONS In IBD patients under maintenance therapy with anti-TNF ANA positivity is associated with lower TLs. The clinical significance of this finding remains to be defined in future larger prospective studies.
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Affiliation(s)
- Eirini Theodoraki
- Department of Gastroenterology, Medical School, University Hospital of Heraklion, University of Crete, P.O. BOX 1352, 71110, Heraklion, Crete, Greece
| | - Eleni Orfanoudaki
- Department of Gastroenterology, Medical School, University Hospital of Heraklion, University of Crete, P.O. BOX 1352, 71110, Heraklion, Crete, Greece
| | - Kalliopi Foteinogiannopoulou
- Department of Gastroenterology, Medical School, University Hospital of Heraklion, University of Crete, P.O. BOX 1352, 71110, Heraklion, Crete, Greece
| | - Nikolaos-Panagiotis Andreou
- Department of Basic Medical Sciences, Laboratory of Biology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Gazouli
- Department of Basic Medical Sciences, Laboratory of Biology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis E Koutroubakis
- Department of Gastroenterology, Medical School, University Hospital of Heraklion, University of Crete, P.O. BOX 1352, 71110, Heraklion, Crete, Greece.
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12
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Zittan E, Steinhart AH, Goldstein P, Milgrom R, Gralnek IM, Silverberg MS. Post-Induction High Adalimumab Drug Levels Predict Biological Remission at Week 24 in Patients With Crohn's Disease. Clin Transl Gastroenterol 2021; 12:e00401. [PMID: 34613952 PMCID: PMC8500561 DOI: 10.14309/ctg.0000000000000401] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 07/29/2021] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION We investigated whether early adalimumab drug levels (ADL) at week 4 predicted biological remission at week 24. METHODS In a prospective study, we assessed clinical and biological remission at weeks 0, 4, 12, and 24 after induction of adalimumab in 33 patients with Crohn's disease. Disease activity was determined by the Harvey-Bradshaw Index, ileocolonoscopy reports, cross-sectional imaging, C-reactive protein (CRP), and fecal calprotectin (FC) levels. Clinical remission was defined as Harvey-Bradshaw Index <5. Biological remission was defined as a combination of FC < 200 μg/g and CRP <5 μg/mL. ADL trough levels were tested using a liquid phase, mobility shift assay. RESULTS At 24 weeks, 18/33 (55%) of the patients were with biological remission. Ten (30%) patients required dose escalation or withdrawal from adalimumab by week 24 because of lack of response and exhibited significantly higher FC (P = 0.003) and CRP (P = 0.002). ADL levels at week 4 (19.8 μg/mL vs 10.2 μg/mL, P = 0.001) were significantly higher in patients with biological remission vs nonresponders at week 24. ADL levels at week 4 were a good predictor of biological remission at week 24, with area under the curve 0.86, 95% confidence interval (1.1; 1.67) and for combined biological and clinical remission, with area under the curve 0.8. The best ADL cutoff at week 4 that predicted biological remission at week 24 was 13.9 μg/mL (sensitivity 94.4% and specificity 73.3%). DISCUSSION In individuals with Crohn's disease, higher adalimumab drug levels at week 4 (>13.9 μg/mL) were significantly associated with biological remission at week 24.
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Affiliation(s)
- Eran Zittan
- The Abraham and Sonia Rochlin IBD Unit, Department of Gastroenterology and Liver Diseases, Emek Medical Center, Afula, Israel
- The Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Canada
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Canada
| | - A. Hillary Steinhart
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Canada
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Canada
| | | | - Raquel Milgrom
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Canada
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Ian M. Gralnek
- The Abraham and Sonia Rochlin IBD Unit, Department of Gastroenterology and Liver Diseases, Emek Medical Center, Afula, Israel
- The Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Mark S. Silverberg
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Canada
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Canada
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13
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Narula N, Wong ECL, AlRamdan R, Bualbanat H, Marshall JK, Steinhart AH, Greener T, Silverberg MS. Comparative effectiveness of higher adalimumab maintenance therapy versus standard dose in anti-tumor necrosis factor experienced Crohn's disease patients: A propensity-score matched cohort analysis. J Gastroenterol Hepatol 2021; 36:2803-2812. [PMID: 34020510 DOI: 10.1111/jgh.15551] [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: 04/04/2021] [Revised: 05/11/2021] [Accepted: 05/19/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Crohn's disease (CD) patients who previously failed anti-tumor necrosis factor (TNF) therapy are at higher risk of treatment failure with subsequent biologics. This study aims to determine the effectiveness and safety of higher maintenance dose regimens of adalimumab compared with standard doses in CD patients who failed anti-TNF. METHODS In this retrospective observational study, CD patients who failed anti-TNF and received adalimumab were categorized according to their post-induction maintenance regimen; 40 mg subcutaneous (sc) weekly or 80 mg sc every other week were defined as a high-dose (HD) maintenance regimen, and 40 mg sc every other week was defined as a standard-dose (SD) maintenance regimen. The primary outcome was time to treatment failure. Cox proportional hazards regression was used to adjust for confounders. Sensitivity analysis was conducted using propensity scores to create a cohort of matched participants with similar distribution of baseline covariates. RESULTS Forty patients started on HD regimens following induction, and 77 patients received the SD regimen. The median time to failure in the HD group was 6.6 years (interquartile range [IQR] 4.0-9.6) and 3.0 years (IQR 0.9-9.4) in the SD group (log-rank test P = 0.006). Patients on HD adalimumab had a lower hazard rate of treatment failure (hazard ratio: 0.27; 95% confidence interval [0.12, 0.62]; P = 0.002) compared with SD patients. No difference in adverse events was identified between groups (30% vs 31.2%, P = 1.0). Results were similar in the propensity score-matched cohort. CONCLUSIONS High-dose maintenance regimens were associated with longer time-to-failure as compared with SD regimens in CD patient who failed anti-TNF.
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Affiliation(s)
- Neeraj Narula
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Emily C L Wong
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Raed AlRamdan
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Hasan Bualbanat
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - John K Marshall
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - A Hillary Steinhart
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital IBD Centre, Toronto, Ontario, Canada.,Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tomer Greener
- Edit Wolfson Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Mark S Silverberg
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital IBD Centre, Toronto, Ontario, Canada.,Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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14
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Greener T, Boland K, Milgrom R, Ben-Bassat O, Steinhart AH, Silverberg MS, Narula N. Higher adalimumab maintenance regimen is more effective than standard dose in anti-TNF experienced Crohn's disease patients. Eur J Gastroenterol Hepatol 2021; 33:1274-1279. [PMID: 34402466 DOI: 10.1097/meg.0000000000002250] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Many Crohn's disease patients treated with anti-tumor necrosis factor (TNF) therapies suffer from loss of response over time and require dose escalation. The aim of this study was to evaluate the efficacy and safety of treating anti-TNF experienced Crohn's disease patients with higher maintenance regimens of adalimumab. METHODS In a retrospective observational study, Crohn's disease patients receiving adalimumab were categorized according to their maintenance regimen; 40 mg weekly, 80 mg every other week or greater were defined as a high-dose maintenance regimen and 40 mg every other week was defined as a standard maintenance regimen. The primary outcome was time to treatment failure. RESULTS Thirty-nine patients were started on high-dose regimens following induction and 40 patients received the standard regimen. According to a Kaplan-Meier survival curve analysis, time to treatment failure was significantly longer in patients in the high-dose group (P = 0.0015). Patients on high-dose adalimumab had a lower treatment failure rate (hazard ratio 0.21; P = 0.0005) when compared to patients on the standard regimen, after adjusting for induction dose and concomitant immunomodulator use. No difference in adverse events was identified between the groups (31 vs. 30%; P = 0.94). CONCLUSION High-dose maintenance regimens were more effective than the standard adalimumab maintenance protocol with better short and long-term clinical outcomes.
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Affiliation(s)
- Tomer Greener
- Digestive Disease Institute, Sha'are Zedek Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Karen Boland
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital IBD Centre, Ontario
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Raquel Milgrom
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital IBD Centre, Ontario
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Ofer Ben-Bassat
- Department of Gastroenterology, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - A Hillary Steinhart
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital IBD Centre, Ontario
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Mark S Silverberg
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital IBD Centre, Ontario
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Neeraj Narula
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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15
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Veisman I, Barzilay O, Bruckmayer L, Haj-Natour O, Kopylov U, Eliakim R, Ben-Horin S, Ungar B. Association of Infliximab and Vedolizumab Trough Levels with Reported Rates of Adverse Events: A Cross-Sectional Study. J Clin Med 2021; 10:jcm10184265. [PMID: 34575376 PMCID: PMC8471987 DOI: 10.3390/jcm10184265] [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: 07/27/2021] [Revised: 09/11/2021] [Accepted: 09/16/2021] [Indexed: 01/04/2023] Open
Abstract
Infliximab and vedolizumab are effective treatments for inflammatory bowel disease (IBD), although associated with adverse events (AE). While low or non-existent drug levels and positive antidrug antibodies have been associated with therapeutic failure, there is no clear association between higher drug levels and AE. A cross-sectional study consisting of Crohn’s disease (CD) and ulcerative colitis (UC) patients receiving infliximab or vedolizumab at the Sheba Medical Center was performed. Patients completed a questionnaire regarding AEs related to biological therapy. Serum trough levels obtained on the same day were analyzed. Objective measures of outcomes were retrieved from medical records. Questionnaires were completed by infliximab (n = 169) and vedolizumab (n = 88)-treated therapy patients. Higher infliximab levels were only numerically associated with the occurrence of at least one AE (p = 0.08). When excluding fatigue and abdominal pain, higher infliximab levels were statistically associated with the occurrence of at least one AE (p = 0.03). Vedolizumab drug levels > 18 μg/mL were also linked with the occurrence of more AEs. No specific association was observed between the increased levels of either infliximab or vedolizumab and specific AEs (neurological symptoms, upper GI symptoms, infectious complications, and musculoskeletal symptoms). As significant AEs are very rare, additional multi-center studies are required.
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Affiliation(s)
- Ido Veisman
- Sheba Medical Center Tel Hashomer, Department of Gastroenterology, Ramat Gan 52620, Israel; (I.V.); (O.B.); (L.B.); (O.H.-N.); (U.K.); (R.E.); (S.B.-H.)
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo 67011, Israel
| | - Oranit Barzilay
- Sheba Medical Center Tel Hashomer, Department of Gastroenterology, Ramat Gan 52620, Israel; (I.V.); (O.B.); (L.B.); (O.H.-N.); (U.K.); (R.E.); (S.B.-H.)
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo 67011, Israel
| | - Liora Bruckmayer
- Sheba Medical Center Tel Hashomer, Department of Gastroenterology, Ramat Gan 52620, Israel; (I.V.); (O.B.); (L.B.); (O.H.-N.); (U.K.); (R.E.); (S.B.-H.)
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo 67011, Israel
| | - Ola Haj-Natour
- Sheba Medical Center Tel Hashomer, Department of Gastroenterology, Ramat Gan 52620, Israel; (I.V.); (O.B.); (L.B.); (O.H.-N.); (U.K.); (R.E.); (S.B.-H.)
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo 67011, Israel
| | - Uri Kopylov
- Sheba Medical Center Tel Hashomer, Department of Gastroenterology, Ramat Gan 52620, Israel; (I.V.); (O.B.); (L.B.); (O.H.-N.); (U.K.); (R.E.); (S.B.-H.)
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo 67011, Israel
| | - Rami Eliakim
- Sheba Medical Center Tel Hashomer, Department of Gastroenterology, Ramat Gan 52620, Israel; (I.V.); (O.B.); (L.B.); (O.H.-N.); (U.K.); (R.E.); (S.B.-H.)
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo 67011, Israel
| | - Shomron Ben-Horin
- Sheba Medical Center Tel Hashomer, Department of Gastroenterology, Ramat Gan 52620, Israel; (I.V.); (O.B.); (L.B.); (O.H.-N.); (U.K.); (R.E.); (S.B.-H.)
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo 67011, Israel
| | - Bella Ungar
- Sheba Medical Center Tel Hashomer, Department of Gastroenterology, Ramat Gan 52620, Israel; (I.V.); (O.B.); (L.B.); (O.H.-N.); (U.K.); (R.E.); (S.B.-H.)
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo 67011, Israel
- Correspondence: ; Tel.: +972-522-605-425
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Papamichael K, Cheifetz AS. Therapeutic Drug Monitoring and Safety of Anti-Tumor Necrosis Factor Therapy in Inflammatory Bowel Disease. Clin Gastroenterol Hepatol 2021; 19:854-855. [PMID: 33248082 DOI: 10.1016/j.cgh.2020.04.088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 04/20/2020] [Accepted: 04/26/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Konstantinos Papamichael
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Adam S Cheifetz
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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17
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Kantasiripitak W, Verstockt B, Alsoud D, Lobatón T, Thomas D, Gils A, Vermeire S, Ferrante M, Dreesen E. The effect of aging on infliximab exposure and response in patients with inflammatory bowel diseases. Br J Clin Pharmacol 2021; 87:3776-3789. [PMID: 33604964 DOI: 10.1111/bcp.14785] [Citation(s) in RCA: 6] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 02/11/2021] [Accepted: 02/13/2021] [Indexed: 12/23/2022] Open
Abstract
AIMS Controversies regarding infliximab treatment in elderly patients with inflammatory bowel diseases remain. We evaluated the effect of patient's age on infliximab exposure, efficacy and safety. METHODS Retrospective case-control data of patients receiving infliximab induction treatment were analysed. A population pharmacokinetic model was developed to estimate individual pharmacokinetic parameters. A logistic regression model was used to investigate the effect of exposure on endoscopic remission. Repeated time-to-event models were developed to describe the hazard of safety events over time. RESULTS A total of 104 patients (46 elderly, ≥65 years) were included. A two-compartment population pharmacokinetic model with linear elimination adequately described the data. Infliximab clearance decreased with older age, higher serum albumin, lower fat-free mass, lower C-reactive protein and absence of immunogenicity. Yet, infliximab exposure was not significantly different between elderly and nonelderly. Regardless of age, an infliximab trough concentration at week (w)14 of 15.6 mg/L was associated with a 50% probability of attaining endoscopic remission between w6 and w22. Infliximab exposure during induction treatment was not a risk factor of (severe) adverse events. The hazard of severe adverse events and malignancy increased by 2% and 7%, respectively, with increasing year of age. Concomitant immunomodulator use increased the hazard of infection by 958%, regardless of age. CONCLUSIONS Elderly patients attained infliximab exposure and endoscopic remission similarly to nonelderly patients. Therefore, the same infliximab trough concentration target can be used in therapeutic drug monitoring. The hazards of severe adverse events and malignancy increased with age, but not with infliximab exposure.
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Affiliation(s)
- Wannee Kantasiripitak
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Dahham Alsoud
- Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Triana Lobatón
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.,Department of Gastroenterology, Ghent University Hospital, Ghent, Belgium
| | - Debby Thomas
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Ann Gils
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Séverine Vermeire
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Marc Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Erwin Dreesen
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Department of Pharmacy, Uppsala University, Uppsala, Sweden
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18
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Landemaine A, Petitcollin A, Brochard C, Miard C, Dewitte M, Le Balc'h E, Grainville T, Bellissant E, Siproudhis L, Bouguen G. Cumulative Exposure to Infliximab, But Not Trough Concentrations, Correlates With Rate of Infection. Clin Gastroenterol Hepatol 2021; 19:288-295.e4. [PMID: 32200087 DOI: 10.1016/j.cgh.2020.03.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [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: 12/10/2019] [Revised: 02/13/2020] [Accepted: 03/08/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Infliximab increases the risk of infection in patients with inflammatory bowel diseases (IBD), but there is controversy over the relationship between drug concentration and infections. We aimed to assess factors associated with infection in infliximab-treated patients, including pharmacokinetic features. METHODS We collected data from 209 patients with IBD (102 men; mean age, 39 y; 159 with Crohn's disease; 54 received combination therapy) who received an infliximab maintenance regimen from November 2016 through April 2017 in France. Data were collected from each infusion visit (total of 640 infusions). Infliximab exposure was estimated based on the area under the curve (AUC) of drug concentration in pharmacokinetic models; individual exposures over the 6-month period were estimated based on the sum of the AUC (ΣAUC). RESULTS The mean infliximab trough level was 5.46 mg/L, and the mean ΣAUC was 3938 ± 1427 mg.d/L. A total of 215 infections were collected from the 640 infusion visits; 123 patients (59%) had at least 1 infection. Factors independently associated with infection after multivariate analysis were smoking (odds ratio [OR], 2.05; P = .046), IBD flare (OR, 2.71; P = .006), and a high ΣAUC of infliximab (above 3234 mg x d/L) (OR, 2.02; P = .02). The ΣAUC was higher in patients with an occurrence of infection (P = .04) and correlated with the number of infections (P = .04). Trough concentration of infliximab alone was not associated with infection. CONCLUSIONS Almost two-thirds of patients treated with infliximab developed an infection; risk was individually correlated with cumulative increase in drug exposure, but not infliximab trough level.
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Affiliation(s)
| | | | - Charlène Brochard
- CHU Rennes, University of Rennes, INSERM, CIC1414, Institut NUMECAN (Nutrition Metabolism and Cancer), Rennes, France
| | - Céline Miard
- CHU Rennes, University of Rennes, Rennes, France
| | | | | | | | | | - Laurent Siproudhis
- CHU Rennes, University of Rennes, INSERM, CIC1414, Institut NUMECAN (Nutrition Metabolism and Cancer), Rennes, France
| | - Guillaume Bouguen
- CHU Rennes, University of Rennes, INSERM, CIC1414, Institut NUMECAN (Nutrition Metabolism and Cancer), Rennes, France.
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19
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Reinhold I, Blümel S, Schreiner J, Boyman O, Bögeholz J, Cheetham M, Rogler G, Biedermann L, Scharl M. Clinical Relevance of Anti-TNF Antibody Trough Levels and Anti-Drug Antibodies in Treating Inflammatory Bowel Disease Patients. Inflamm Intest Dis 2020; 6:38-47. [PMID: 33850838 DOI: 10.1159/000511296] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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: 03/31/2020] [Accepted: 08/31/2020] [Indexed: 12/16/2022] Open
Abstract
Background and Aims The majority of patients treated with anti-tumor necrosis factor (TNF) therapy develop anti-drug antibodies (ADAs), which might result in loss of treatment efficacy. Strict guidelines on measuring trough levels (TLs) and ADA in clinical routine do not exist. To provide real-world data, we took advantage of our tertiary inflammatory bowel disease (IBD) center patient cohort and determined indicators for therapeutic drug monitoring (TDM) and actual consequences in patient care. Methods We retrospectively collected clinical data of 104 IBD patients treated with infliximab or adalimumab in our IBD clinic. Patients with TL and ADA measurements between June 2015 and February 2018 were included. Results The main reason for determining TL was increased clinical disease. Subtherapeutic TLs were found in 33 patients, therapeutic TLs in 33 patients, and supratherapeutic TLs in 38 patients. Adjustments in anti-TNF therapy occurred more frequently (p = 0.01) in patients with subtherapeutic TL (24 of 33 patients; 73%) as compared to patients with therapeutic and supratherapeutic TLs (26 of 71 patients; 37%). No correlation could be found between TL and disease activity (p = 0.16). Presence of ADA was found in 16 patients, correlated with the development of infusion reactions (OR: 10.6, RR: 5.4, CI: 2.9-38.6), and was associated with subtherapeutic TL in 15 patients (93.8%). Treatment adaptations were based on TL and/or ADA presence in 36 of 63 patients. Conclusions TDM showed significant treatment adaptations in patients with subtherapeutic TL. Conversely, in patients with therapeutic and supratherapeutic TLs, reasons for adaptations were based on considerations other than TL, such as clinical disease activity. Further studies should focus on decision-making in patients presenting with supratherapeutic TL in remission.
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Affiliation(s)
- Ilana Reinhold
- Department of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Department of Internal Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Sena Blümel
- Department of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Jens Schreiner
- Department of Immunology, University Hospital Zurich, Zurich, Switzerland
| | - Onur Boyman
- Department of Immunology, University Hospital Zurich, Zurich, Switzerland.,Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Jan Bögeholz
- Department of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Department of Internal Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Marcus Cheetham
- Department of Internal Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Gerhard Rogler
- Department of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Luc Biedermann
- Department of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Michael Scharl
- Department of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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20
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Assa A, Dorfman L, Shouval DS, Shamir R, Cohen S. Therapeutic Drug Monitoring-guided High-dose Infliximab for Infantile-onset Inflammatory Bowel Disease: A Case Series. J Pediatr Gastroenterol Nutr 2020; 71:516-20. [PMID: 32639454 DOI: 10.1097/MPG.0000000000002832] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Very early-onset inflammatory bowel disease (IBD) and specifically infantile-onset IBD patients, are characterized by high rates of extensive colonic involvement and decreased response rate to standard therapeutic regimens, including infliximab (IFX). We present a case series of 4 patients with infantile-onset IBD achieving clinical and biologic remission, after treatment with therapeutic drug monitoring (TDM)-guided accelerated high-dose IFX therapy. All patients were treated with accelerated high-dose IFX induction of up to 22 mg/kg. In 3 of these patients, accelerated high-dose IFX was used following failure of intensified standard dose induction. All patients achieved remission following re-induction.We suggest that children with infantile-onset IBD may require a TDM-guided accelerated high-dose IFX induction and maintenance treatment in order to achieve and maintain remission. Personalized approach in these patients is essential in order to prevent underdosing and to avoid inappropriate interpretation of treatment failure.
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21
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Theodoraki E, Orfanoudaki E, Foteinogiannopoulou K, Legaki E, Gazouli M, Koutroubakis IE. Is there a correlation between infliximab trough levels and the development of adverse events in patients with inflammatory bowel disease? Intest Res 2020; 19:461-467. [PMID: 32806874 PMCID: PMC8566825 DOI: 10.5217/ir.2020.00042] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 05/02/2020] [Accepted: 05/25/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/AIMS The measurement of infliximab trough levels (IFX-TLs) in patients with inflammatory bowel disease (IBD) is performed to optimize treatment. However, the association between the development of adverse events (AEs) and IFX-TLs has not been sufficiently studied thus far. To investigate the possible association of IFX-TLs with AEs in Greek patients with IBD receiving maintenance treatment with IFX. METHODS A retrospective analysis of the registry data of the Gastroenterology Department of the University Hospital of Heraklion, from IBD patients with at least one available IFX-TL measurement during the years 2016 to 2017 was conducted. AEs reported 4 months before and 4 months after the measured IFX-TLs were recorded. The IFX-TLs of patients with or without AEs were compared. RESULTS Of a total of 83 IBD patients (61 Crohn's disease [73%]; 52 men [63%]; mean age ± standard deviation, 43.3 ± 16.0 years), 147 measurements of IFX-TLs were available (median 4.69 μg/ mL [1.32-9.16]), and 99 AEs (67.3%, 14 severe) were registered. The median IFX-TL of patients with AEs was 5.79 μg/mL (1.36- 10.25), higher than the median IFX-TL of patients without AEs (3.40 μg/mL [1.30-5.92]), but the difference was not significant (P= 0.97). The presence of infections or dermatologic reactions was not correlated with IFX-TLs. There was no difference in the prevalence of the total AEs (66.7% vs. 73.3%, P= 0.77) or in the analysis of AEs by group between patients with IFX-TLs ≥ 15 μg/ mL and patients with IFX-TLs < 15 μg/mL. CONCLUSIONS IFX-TLs are not significantly associated with the development of AEs in IBD patients receiving maintenance treatment with IFX.
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Affiliation(s)
- Eirini Theodoraki
- Department of Gastroenterology, University Hospital of Heraklion, Medical School University of Crete, Heraklion, Greece
| | - Eleni Orfanoudaki
- Department of Gastroenterology, University Hospital of Heraklion, Medical School University of Crete, Heraklion, Greece
| | - Kalliopi Foteinogiannopoulou
- Department of Gastroenterology, University Hospital of Heraklion, Medical School University of Crete, Heraklion, Greece
| | - Evangelia Legaki
- Department of Basic Medical Sciences, Laboratory of Biology, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Maria Gazouli
- Department of Basic Medical Sciences, Laboratory of Biology, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Ioannis E Koutroubakis
- Department of Gastroenterology, University Hospital of Heraklion, Medical School University of Crete, Heraklion, Greece
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22
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Pinto Pais I, Espinheira MC, Trindade E, Amil Dias J. Optimizing Antitumor Necrosis Factor Treatment in Pediatric Inflammatory Bowel Disease With Therapeutic Drug Monitoring. J Pediatr Gastroenterol Nutr 2020; 71:12-8. [PMID: 32142005 DOI: 10.1097/MPG.0000000000002704] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Biological agents have revolutionized inflammatory bowel disease treatment but primary nonresponse and secondary loss of response are common with resulting adverse outcomes. Clinical trials demonstrated an association between serum drug concentrations, as well as the presence of antidrug antibodies, and loss-of-response. Therapeutic drug monitoring (TDM), defined as the evaluation of drug concentrations and antidrug antibodies, is appearing as a strategy to optimize treatment and take full advantage from these drugs. TDM appears to be a promising tool in clinical practice, especially in pediatric patients, who have pronounced fluctuations in the pharmacokinetics of the drugs.The authors present a literature review about antitumor necrosis factor therapy optimization based on personalized treatment strategies according to TDM and possible strategies to recapture loss of response, including an algorithm for practical management.
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23
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Battat R. Editorial: calcineurin inhibitors as a bridge to vedolizumab for severe ulcerative colitis. Aliment Pharmacol Ther 2020; 51:663-664. [PMID: 32100351 DOI: 10.1111/apt.15632] [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)
- Robert Battat
- Jill Roberts Center for IBD, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY, USA
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24
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Grinman AB, de Souza MDGC, Bouskela E, Carvalho ATP, de Souza HSP. Clinical and laboratory markers associated with anti-TNF-alpha trough levels and anti-drug antibodies in patients with inflammatory bowel diseases. Medicine (Baltimore) 2020; 99:e19359. [PMID: 32150077 PMCID: PMC7478556 DOI: 10.1097/md.0000000000019359] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Monitoring anti-TNF agents in inflammatory bowel disease (IBD) patients may be helpful in optimizing outcomes. We aimed to evaluate potential correlations among demographic, clinical, laboratory, or imaging parameters, as well as serum levels of infliximab (IFX) and adalimumab (ADA) and their respective antibodies, in the clinical management of IBD patients.A cross-sectional study of 95 patients with Crohn's disease (CD) or ulcerative colitis (UC) in maintenance therapy with infliximab or adalimumab was performed. Drug trough levels and anti-drug levels were determined using ELISA-based assays.Regarding the serum IFX dosage, patients with higher relative C-reactive protein (CRP) levels had significantly lower relative serum IFX levels (<3 μg/mL) (P = .028). In contrast, higher concentrations of anti-IFX antibodies were found in patients who were not on concomitant immunomodulators (P = .022) and who had more biological-related adverse events (P = .001) and higher levels of CRP (P = .042). Serum CRP levels were also negatively correlated with IFX (CC = -0.315; P = .033) but positively correlated with the presence of IFX antibodies (CC = 0.327; P = .027). Serum albumin dosage showed a positive correlation with levels of both IFX (CC = 0.379; P = .004) and ADA (CC = 0.699; P = .003).Although anti-TNF-α trough levels and immunogenicity do not show a significant correlation with disease outcome, our results reinforce the use of combination therapy for patients treated with infliximab. Moreover, we confirmed the presence of significant associations between anti-TNF-α trough levels and immunogenicity with body mass index (BMI), the concomitant use of immunomodulators, the rates of side effects, and laboratory markers, including serum albumin and CRP.
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Affiliation(s)
| | | | - Eliete Bouskela
- Department of Physiological Sciences, State University of Rio de Janeiro, Rio de Janeiro, RJ, 20551-900, Brazil
| | | | - Heitor S. P. de Souza
- Department of Internal Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, 1. Rio de Janeiro, Rio de Janeiro, RJ, 21941-913
- D’Or Institute for Research and Education (IDOR), Rua Diniz Cordeiro 30, Botafogo, Rio de Janeiro, RJ 22281-100, Brazil
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25
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Gibson DJ, Ward MG, Rentsch C, Friedman AB, Taylor KM, Sparrow MP, Gibson PR. Review article: determination of the therapeutic range for therapeutic drug monitoring of adalimumab and infliximab in patients with inflammatory bowel disease. Aliment Pharmacol Ther 2020; 51:612-628. [PMID: 31961001 DOI: 10.1111/apt.15643] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 10/14/2019] [Accepted: 01/07/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Clinical application of therapeutic drug monitoring (TDM) to optimise anti-TNF therapies in patients with IBD depends upon target ranges. AIMS To review methodology used to determine therapeutic ranges and critically compare and contrast its application to infliximab and adalimumab. METHODS A systematic review was performed, and relevant literature was summarised and critically examined. RESULTS Upper limits of the therapeutic range are determined by toxicity, a plateau response and cost. Lower limits are determined by optimal concentration on the target of action in vitro and/or in vivo, or by correlation of drug levels with clinical efficacy using area-under-receiver-operator-curve (AUROC) analysis. In 43 studies, there were huge variations in time at which infliximab and adalimumab levels were measured, the end-points used (clinical remission to mucosal healing), the clinical setting (active disease vs maintenance phase) and the reason for TDM (proactive vs reactive). In the maintenance phase for infliximab, lower trough limits 2.8-5.7 µg/mL are reported depending upon end-points used, with consistent AUROC 0.68-0.77. Adalimumab TDM targets are even less consistent with a lower limit 5.9-11.8 µg/mL (AUROC 0.66-0.83) in some studies, but no cut-off can be identified that is significantly associated with outcome in others, related to inherent pharmacokinetic and pharmacodynamic differences, and heterogeneity of study design. CONCLUSIONS Evidence for exposure-response relationship is stronger for infliximab than adalimumab. Due to heterogeneity in settings for drug level measurements, therapeutic ranges vary. These factors need to be taken into account when interpreting the evidence and extending this to therapeutic strategies for IBD patients.
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Affiliation(s)
- David J Gibson
- Departments of Gastroenterology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Mark G Ward
- Departments of Gastroenterology, The Alfred Hospital, Melbourne, VIC, Australia.,Monash University, Melbourne, VIC, Australia
| | | | - Antony B Friedman
- Departments of Gastroenterology, The Alfred Hospital, Melbourne, VIC, Australia.,Monash University, Melbourne, VIC, Australia
| | - Kirstin M Taylor
- Departments of Gastroenterology, The Alfred Hospital, Melbourne, VIC, Australia.,Monash University, Melbourne, VIC, Australia
| | - Miles P Sparrow
- Departments of Gastroenterology, The Alfred Hospital, Melbourne, VIC, Australia.,Monash University, Melbourne, VIC, Australia
| | - Peter R Gibson
- Departments of Gastroenterology, The Alfred Hospital, Melbourne, VIC, Australia.,Monash University, Melbourne, VIC, Australia
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26
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Lie MRKL, Paulides E, van der Woude CJ. Patient sex does not affect endoscopic outcomes of biologicals in inflammatory bowel disease but is associated with adverse events. Int J Colorectal Dis 2020; 35:1489-1500. [PMID: 32592091 PMCID: PMC7340671 DOI: 10.1007/s00384-020-03663-2] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Biological therapies are currently the mainstay in the treatment of patients with inflammatory bowel diseases (IBD). Several factors are known to influence the efficacy and tolerability of biologicals, such as CRP levels or previous biological use. Whether patient sex affects the efficacy or tolerability is unclear but would help with better risk and benefit stratification. This systematic review assesses patient sex on the efficacy and tolerability of biological therapies in IBD patients. METHODS A systematic literature review was performed using Embase (including MEDLINE), MEDLINE OvidSP, Cochrane Central Register of Controlled Trials, Web of Science and PubMed. The primary outcome was the influence of patient sex on endoscopic outcomes in IBD patients treated with biologicals. The secondary outcome was the influence of patient sex on adverse events. Studies were included in the assessment regardless of study type or setting. RESULTS The search yielded 19,461 citations; after review, 55 studies were included in the study, involving 28,465 patients treated with adalimumab, certolizumab pegol, infliximab, or vedolizumab. There was no significant association between patient sex and endoscopic efficacy in 41 relevant studies. Increased adverse events were associated with female sex in 7 out of 14 relevant studies. CONCLUSIONS There is no evidence for a sex difference in endoscopically measured response to biological therapies in IBD patients. However, there is an influence of sex on the occurrence of adverse events.
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Affiliation(s)
- Mitchell R. K. L. Lie
- Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, The Netherlands
| | - Emma Paulides
- Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, The Netherlands
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27
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Jongsma MME, Winter DA, Huynh HQ, Norsa L, Hussey S, Kolho KL, Bronsky J, Assa A, Cohen S, Lev-Tzion R, Van Biervliet S, Rizopoulos D, de Meij TGJ, Shouval DS, Wine E, Wolters VM, Martinez-Vinson C, de Ridder L; Paediatric IBD Porto Group of ESPGHAN. Infliximab in young paediatric IBD patients: it is all about the dosing. Eur J Pediatr 2020; 179:1935-44. [PMID: 32813123 DOI: 10.1007/s00431-020-03750-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/16/2020] [Accepted: 07/21/2020] [Indexed: 12/14/2022]
Abstract
Infliximab (IFX) is administered intravenously using weight-based dosing (5 mg/kg) in inflammatory bowel disease (IBD) patients. Our hypothesis is that especially young children need a more intensive treatment regimen than the current weight-based dose administration. We aimed to assess IFX pharmacokinetics (PK), based on existing therapeutic drug monitoring (TDM) data in IBD patients < 10 years. TDM data were collected retrospectively in 14 centres. Children treated with IFX were included if IFX was started as IBD treatment at age < 10 years (young patients, YP) and PK data were available. Older IBD patients aged 10-18 years were used as controls (older patients, OP). Two hundred and fifteen paediatric inflammatory bowel disease (PIBD) patients were eligible for the study (110 < 10 year; 105 ≥ 10 years). Median age was 8.3 years (IQR 6.9-8.9) in YP compared with 14.3 years (IQR 12.8-15.6) in OP at the start of IFX. At the start of maintenance treatment, 72% of YP had trough levels below therapeutic range (< 5.4 μg/mL). After 1 year of scheduled IFX maintenance treatment, YP required a significantly higher dose per 8 weeks compared with OP (YP; 9.0 mg/kg (IQR 5.0-12.9) vs. OP; 5.5 mg/kg (IQR 5.0-9.3); p < 0.001). The chance to develop antibodies to infliximab was relatively lower in OP than YP (0.329 (95% CI - 1.2 to - 1.01); p < 0.001), while the overall duration of response to IFX was not significantly different (after 2 years 53% (n = 29) in YP vs. 58% (n = 45) in OP; p = 0.56).Conclusion: Intensification of the induction scheme is suggested for PIBD patients aged < 10 years. What is Known? •Infliximab trough levels of paediatric IBD patients are influenced by several factors as dosing scheme, antibodies and inflammatory markers. •In 4.5-30% of the paediatric IBD patients, infliximab treatment was stopped within the first year. What is New? •The majority of young PIBD (< 10 years) have inadequate IFX trough levels at the start of maintenance treatment. •Young PIBD patients (< 10 years) were in need of a more intensive treatment regimen compared with older paediatric patients during 1 year of IFX treatment. •The chance to develop antibodies to infliximab was relatively higher in young PIBD patients (< 10 years).
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28
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Abstract
Inflammatory bowel disease (IBD) with pediatric onset has become more prevalent during past decades. Thus, the number of patients with moderate to severe disease subtype treated with antagonists to tumor necrosis factor alpha (TNFα) has concurrently risen. Most pediatric patients initially respond to these drugs but will need dose escalation during the first year of therapy. As pediatric data regarding therapeutic drug monitoring during therapy with TNFα-blocker adalimumab are sparse, this review focuses on the literature on therapeutic drug monitoring of infliximab and how it may guide management.
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Affiliation(s)
- Kaija-Leena Kolho
- Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.,Faculty of Medicine and Medical Technology, Tampere University, Tampere, Finland
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29
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Abstract
As the incidence of inflammatory bowel disease (IBD) rises and the global population ages, the number of older people living with these conditions will inevitably increase. The challenges posed by comorbid conditions, polypharmacy, the unintended consequences of long-term treatment and the real but often underestimated mismatch between chronological and biological ages underpin management. Significantly, there may be differences in disease characteristics, presentation and management of an older patient with IBD, together with other unique challenges. Importantly, clinical trials often exclude older patients, so treatment decisions are frequently pragmatic, extrapolated from a number of sources of evidence and perhaps primarily dictated by concerns around adverse effects. This review aimed to discuss the epidemiology, clinical features and considerations with management in older patients with IBD.
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Affiliation(s)
| | | | - Jimmy Limdi
- Section of IBD, Division of Gastroenterology, The Pennine Acute Hospitals NHS Trust, Manchester, UK,Department of Gastroenterology, Manchester Academic Health Science Centre, Manchester, UK
| | - Bu'Hussain Hayee
- Department of Gastroenterology, King's College Hospital, London, UK
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30
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Bodini G, Demarzo MG, Saracco M, Coppo C, De Maria C, Baldissarro I, Savarino E, Savarino V, Giannini EG. High anti-TNF alfa drugs trough levels are not associated with the occurrence of adverse events in patients with inflammatory bowel disease. Scand J Gastroenterol 2019; 54:1220-1225. [PMID: 31553630 DOI: 10.1080/00365521.2019.1666914] [Citation(s) in RCA: 4] [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] [Indexed: 02/04/2023]
Abstract
Objectives: Up to 40% of inflammatory bowel disease (IBD) patients treated with anti-TNF drugs lose response within 1 year of treatment, therefore requiring drug optimization. Although higher drug trough levels (TLs) are associated with sustained clinical outcomes, there are concerns that they may be associated with a higher risk of adverse events (AEs). The aim was to evaluate the presence of a possible association between drug TLs and the occurrence of AEs in IBD patients treated with anti-TNF drugs.Methods: We retrospectively studied a cohort of 113 IBD patients treated with adalimumab or infliximab, of whom 27 were in combination therapy with immunosuppressants. TLs were measured using a homogeneous mobility shift assay.Results: During a median follow-up of 16 months (range 1-144), we observed 103 AEs occurring in 58 patients. We found no statistically significant difference (p = .21) in median TLs between patients who did 6.7 mcg/mL; range 0.0-36.2) or did not (7.7 mcg/mL; range 0.0-20.7) experience an AE. No difference was observed in the rate of AEs between patients in mono- or combination therapy (p = .38), as well as between elderly (i.e., >65 years) and younger patients (p = .32). Considering a TL cutoff of 7 mcg/mL for infliximab and 12 mcg/mL for adalimumab, or even double these TL values, we observed no statistically significant difference in the rate of AEs occurrence.Conclusion: Our study suggests that, when clinically required, anti-TNF drug dosage may be increased without particular concerns regarding the risk of AEs occurrence in IBD patients, even in patients on combination therapy and elderly ones.
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Affiliation(s)
- Giorgia Bodini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Maria Giulia Demarzo
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Margherita Saracco
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Claudia Coppo
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Costanza De Maria
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Isabella Baldissarro
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Edoardo Savarino
- Gastroenterolgy Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Vincenzo Savarino
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Edoardo G Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
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Assa A, Matar M, Turner D, Broide E, Weiss B, Ledder O, Guz-Mark A, Rinawi F, Cohen S, Topf-Olivestone C, Shaoul R, Yerushalmi B, Shamir R. Proactive Monitoring of Adalimumab Trough Concentration Associated With Increased Clinical Remission in Children With Crohn's Disease Compared With Reactive Monitoring. Gastroenterology 2019; 157:985-996.e2. [PMID: 31194979 DOI: 10.1053/j.gastro.2019.06.003] [Citation(s) in RCA: 147] [Impact Index Per Article: 29.4] [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: 02/20/2019] [Revised: 06/02/2019] [Accepted: 06/05/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND & AIMS Proactive monitoring of drug trough concentrations and antibodies against drugs might help determine whether patients are likely to respond to treatment and increase efficacy. We investigated whether proactive drug monitoring is associated with higher rates of clinical remission in pediatric patients with Crohn's disease (CD). METHODS We performed a nonblinded, randomized controlled trial of 78 children with CD (6-18 years old; 29% female; mean age, 14.3 ± 2.6 years) who had not received prior treatment with a biologic agent but had responded to adalimumab induction therapy, under scheduled monitoring of clinical and biologic measures (based on clinical factors and levels of C-reactive protein and fecal calprotectin), at pediatric gastroenterology units in Israel from July 2015 through December 2018. The patients were randomly assigned to groups that received proactive monitoring (trough concentrations measured at weeks 4 and 8 and then every 8 weeks until week 72, n = 38) or reactive monitoring (physicians were informed of trough concentrations after loss of response, n = 40). In both groups, doses and intervals of adalimumab were adjusted to achieve trough concentrations of 5 μg/mL. The primary endpoint was sustained corticosteroid-free clinical remission at all visits (week 8 through week 72). RESULTS The primary endpoint was achieved by 31 children (82%) in the proactive group and 19 children (48%) in the reactive group (P = .002). Sixteen patients in the proactive monitoring group (42%) achieved a composite outcome of sustained corticosteroid-free remission, C-reactive protein ≤0.5 mg/dL, and level of fecal calprotectin ≤150 μg/g compared with 5 patients in the reactive monitoring group (12%) (P = .003). By week 72 of treatment, 33 patients in the proactive monitoring group had received adalimumab intensification (87%) compared with 24 patients in the reactive monitoring group (60%) (P = .001). CONCLUSIONS In a randomized controlled trial of pediatric patients with CD, we found that proactive monitoring of adalimumab trough concentrations and adjustment of doses and intervals resulted in significantly higher rates corticosteroid-free clinical remission than reactive monitoring (measuring trough concentration after loss of response). Clinicaltrials.gov no.: NCT02256462.
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Affiliation(s)
- Amit Assa
- The Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Hospital, Petach-Tikva, Israel; The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Manar Matar
- The Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Hospital, Petach-Tikva, Israel
| | - Dan Turner
- The Juliet Keidan Institute of Pediatric Gastroenterology, Nutrition, Shaare Zedek Medical Center, The Hebrew University, Jerusalem, Israel
| | - Efrat Broide
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Pediatric Gastroenterology Unit, Assaf Harofeh Medical Center, Zerifin, Israel
| | - Batia Weiss
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Pediatric Gastroenterology Unit, Sheba Medical Center, Edmond and Lily Safra Childen's Hospital, Ramat-Gan, Tel-Hashomer, Israel
| | - Oren Ledder
- The Juliet Keidan Institute of Pediatric Gastroenterology, Nutrition, Shaare Zedek Medical Center, The Hebrew University, Jerusalem, Israel
| | - Anat Guz-Mark
- The Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Hospital, Petach-Tikva, Israel; The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Firas Rinawi
- The Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Hospital, Petach-Tikva, Israel; The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shlomi Cohen
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Pediatric Gastroenterology Unit, "Dana-Dwek" Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | | | - Ron Shaoul
- Pediatric Gastroenterology Unit, Rambam Medical Center, Haifa, Israel
| | - Baruch Yerushalmi
- Pediatric Gastroenterology Unit, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Raanan Shamir
- The Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Hospital, Petach-Tikva, Israel; The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Abstract
The era of biologic agents for the treatment of Crohn’s disease has brought about significant benefits for patients, and since the introduction of infliximab at the turn of the century, the entire field has moved on rapidly. Clinicians now have multiple agents at their disposal and a choice between several different anti-inflammatory mechanisms of action. This has allowed unprecedented improvements not only in symptoms and quality of life for patients previously refractory to conventional treatments but also for demonstrated healing of the intestinal mucosa and resolution of perianal fistulation. However, despite the undisputed efficacy of these agents, there remains a significant proportion of patients who fail to gain a meaningful benefit. Through years of studying infliximab and its counterpart anti-tumour necrosis factor (anti-TNF) agent, adalimumab, we now understand that strategies such as combining use with a conventional immunomodulator or measuring serum levels can help to optimise outcomes and reduce the proportion of patients for whom treatment fails. Work is ongoing to understand whether these principles apply to newer biologics such as vedolizumab and ustekinumab. In addition, novel approaches are being investigated in an attempt to maximise the benefit that these agents could offer. In this article, we summarise these new understandings and consider ways in which they could be integrated into clinical practice for the benefit of patients.
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Affiliation(s)
- Mark Samaan
- Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Samantha Campbell
- Department of Gastroenterology, Royal Free London NHS Foundation Trust, London, UK
| | - Georgina Cunningham
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Peter M Irving
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Sara McCartney
- Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, London, UK
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Strik AS, Berends SE, Löwenberg M. Therapeutic drug monitoring-based dosing of TNF inhibitors in inflammatory bowel disease: the way forward? Expert Rev Clin Pharmacol 2019; 12:885-891. [PMID: 31305158 DOI: 10.1080/17512433.2019.1642745] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: Secondary loss of response to anti-tumor necrosis factor (TNF) therapy remains a challenge in the clinical management of inflammatory bowel disease (IBD) patients. A frequently observed reason for secondary loss of response to TNF blockers is inadequate drug exposure and sub-therapeutic serum drug concentrations. Areas covered: This review presents an overview of recent research on therapeutic drug monitoring (TDM)-based dosing with anti-TNF agents in IBD. The role of reactive and proactive TDM and different approaches on how to optimize anti-TNF treatment are discussed. Expert opinion: Due to variations within and between patients, the 'one size fits all' theory does not apply to all IBD patients receiving anti-TNF agents. Timing of TDM (i.e. reactive versus proactive) is a matter of debate. Both strategies might optimize anti-TNF treatment, although most trials did not show a clinical benefit compared to conventional dosing up to now. So-called dashboard systems might have an additive value in the optimization of anti-TNF treatment, since these tools enable clinicians to really personalize anti-TNF treatment.
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Affiliation(s)
- Anne S Strik
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam , Amsterdam , Netherlands
| | - Sophie E Berends
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam , Amsterdam , Netherlands.,Hospital Pharmacy, Amsterdam UMC, University of Amsterdam , Amsterdam , Netherlands
| | - Mark Löwenberg
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam , Amsterdam , Netherlands
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Abstract
PURPOSE OF REVIEW The current review provides an updated overview on the role of therapeutic drug monitoring (TDM) of biological therapies in inflammatory bowel disease (IBD). We examine the data behind TDM for the antitumor necrosis factor agents, vedolizumab and ustekinumab, in patients with IBD. In addition, we discuss reactive vs. proactive TDM. RECENT FINDINGS There is a positive correlation between biologic drug concentrations and favorable therapeutic outcomes in IBD, although the majority of data refer to antitumor necrosis factor therapy. Reactive TDM has rationalized the management of patients with IBD with loss of response to biological therapy. Moreover, reactive TDM of infliximab has been proven to be more cost-effective when compared with empiric dose optimization. Preliminary data suggest that proactive TDM of infliximab and adalimumab applied in patients with clinical response/remission is associated with better therapeutic outcomes compared with standard of care (empiric treatment and/or reactive TDM). SUMMARY For all biologics in IBD, there is a positive correlation between drug concentrations and favorable therapeutic outcomes. Reactive TDM is the new standard of care for optimizing biologic therapies in IBD, whereas recent data suggest an important role of proactive TDM for optimizing antitumor necrosis factor therapy in IBD.
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Giannini EG, Demarzo MG, Bodini G. Reproducibility and Transportability of the Absence of Incremental Infectious Adverse Events in Patients With Higher Anti-TNF Drug Levels. Inflamm Bowel Dis 2019; 25:e73. [PMID: 30597035 DOI: 10.1093/ibd/izy390] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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)
- Edoardo G Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Ospedale Policlinico San Martino-IRCCS per l'Oncologia, Genoa, Italy
| | - Maria Giulia Demarzo
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Ospedale Policlinico San Martino-IRCCS per l'Oncologia, Genoa, Italy
| | - Giorgia Bodini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Ospedale Policlinico San Martino-IRCCS per l'Oncologia, Genoa, Italy
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Abstract
Background: The relationship between serum adalimumab concentrations and adverse events in patients with inflammatory bowel disease (IBD) is unknown. We aimed to determine whether patients with IBD using adalimumab are at increased risk of adverse events if they have higher adalimumab serum levels compared to those with lower adalimumab levels. Methods: This was a retrospective study of 191 IBD patients with at least one serum adalimumab level measurement available. The cohort was divided using a cutoff level of 10 mcg/mL. The primary outcome was the rate of overall adverse events between the two groups. Secondary outcomes included rate of infections, dermatologic reactions, injection-site reactions and other adverse events in both groups. Rates of discontinuation of adalimumab due to adverse events were evaluated. Multivariate logistic regression analysis was performed to evaluate the relationship between adalimumab levels and adverse events. Results: A total of 41 adverse events were reported in 191 patients in the overall cohort. Among 86 patients with higher adalimumab levels, 22 adverse events were reported, vs. 19 adverse events among 105 patients with lower adalimumab levels (25.6% vs. 18.1%, p = .21). Analysis according to adalimumab level tertiles also did not show significant differences in the rates of adverse events. A multivariate forward selection model also did not find higher odds of an adverse event in IBD patients with higher adalimumab levels compared to lower levels (OR 1.54, 95% CI 0.77-3.08). Conclusions: There does not appear to be a relationship between adalimumab exposure and risk of adverse events in IBD patients.
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Affiliation(s)
- Neeraj Narula
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University , Hamilton , Canada
| | - Brian Lauzon
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University , Hamilton , Canada
| | - John K Marshall
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University , Hamilton , Canada
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Drobne D, Kurent T, Golob S, Švegl P, Rajar P, Hanžel J, Koželj M, Novak G, Smrekar N, Ferkolj I, Štabuc B. Optimised infliximab monotherapy is as effective as optimised combination therapy, but is associated with higher drug consumption in inflammatory bowel disease. Aliment Pharmacol Ther 2019; 49:880-889. [PMID: 30784100 DOI: 10.1111/apt.15179] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 10/01/2018] [Accepted: 01/16/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Combination treatment with azathioprine for 6-12 months is the preferred strategy for starting infliximab due to improved pharmacokinetics. However, optimised infliximab monotherapy with proactive dose escalations in case of low trough levels is a safer but under-studied alternative. AIM To compare the clinical success and infliximab consumption of combination vs optimised monotherapy strategies. METHODS We studied the clinical success and infliximab consumption of both strategies in 149 patients (94 Crohn's disease; 55 ulcerative colitis) starting infliximab and undergoing intensive drug monitoring assisted treatment optimisation. RESULTS The drug retention rates were similar for optimised monotherapy and combination treatment after induction (96% vs 97%, P = 0.73), after the first year (90% vs 83%, P = 0.23) and at the end of follow-up (74% vs 75%, P = 0.968). Similarly, no differences were observed for steroid use at year 1 (5% vs 14%, P = 0.08) or mucosal healing at the end of follow-up (64% vs 67%, P = 0.8). Higher infliximab consumption (7.6 mg/kg q8 weeks [interquartile range (IQR): 5.9-10.3] vs 6.4 mg/kg q8 weeks [IQR: 5.2-8.0], P = 0.019) combined with lower trough levels (1.7 µg/mL [IQR: 0.3-6.6] vs 5.0 µg/mL [2.5-8.7], P = 0.012) resulted in almost 3-fold higher drug-to-trough ratio (3.9 vs 1.5) in monotherapy compared to combination strategy at year 1. At the end of follow-up, when azathioprine had been discontinued for a median of 14 [IQR: 3-33] months, these differences disappeared. CONCLUSIONS In this study, optimised infliximab monotherapy was as clinically effective as combination therapy but was associated with significantly higher infliximab consumption. The infliximab-sparing effect disappeared after azathioprine withdrawal.
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Affiliation(s)
- David Drobne
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Tina Kurent
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Saša Golob
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Polona Švegl
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Polona Rajar
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Jurij Hanžel
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Matic Koželj
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Gregor Novak
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Nataša Smrekar
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Ivan Ferkolj
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Borut Štabuc
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
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Verstockt B, Verstockt S, Creyns B, Tops S, Van Assche G, Gils A, Ceuppens JL, Vermeire S, Ferrante M, Breynaert C. Mucosal IL13RA2 expression predicts nonresponse to anti-TNF therapy in Crohn's disease. Aliment Pharmacol Ther 2019; 49:572-581. [PMID: 30663072 PMCID: PMC6849553 DOI: 10.1111/apt.15126] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 11/04/2018] [Accepted: 12/13/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Ileocolonic expression of IL13RA2 has been identified as a predictive marker for nonresponsiveness to infliximab (IFX) in patients with Crohn's disease (CD). AIM To validate the IL13RA2 biomarker, study its anti-TNF specificity and get a better understanding of the underlying biology driving its expression. METHODS IL13RA2 mucosal expression was studied in a cohort of adalimumab and vedolizumab treated patients. To identify the upstream regulators of anti-TNF nonresponsiveness, weighted gene co-expression network analysis was applied on publicly available microarray data of IFX-treated patients. Selected serum proteins, including TNF, were measured prior to first IFX exposure and compared between healers and nonhealers. RESULTS Increased mucosal IL13RA2 expression prior to start of biological therapy was predictive for anti-TNF nonresponsiveness specifically (AUROC, area under the curve = 0.90, P < 0.001 in anti-TNF vs AUROC = 0.63, P = 0.30 in vedolizumab treated patients). In baseline biopsies, TNF-driven pathways were significantly enriched in future anti-TNF nonhealers (P = 5.0 × 10-34 ). We found an increased baseline mucosal TNF burden in nonhealers (P = 0.02), and TNF mRNA correlated significantly with IL13RA2 expression (ρ = 0.55, P = 0.02). Baseline serum TNF levels were significantly lower in nonhealers (P = 0.04), and correlated inversely with IFX serum induction levels (r = -0.45, P = 0.002 at week 6). CONCLUSIONS Increased mucosal IL13RA2 expression is associated with an increased mucosal TNF burden in CD patients. In view of its specificity for prediction of anti-TNF therapy resistance, mucosal IL13RA2 expression is a potential biomarker for therapy selection and/or for the need of increased anti-TNF drug dosing.
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Affiliation(s)
- Bram Verstockt
- Department of Chronic Diseases, Metabolism and AgeingTranslational Research Center for Gastrointestinal Disorders (TARGID), KU LeuvenLeuvenBelgium,Department of Gastroenterology and HepatologyUniversity Hospitals Leuven, KU LeuvenLeuvenBelgium
| | - Sare Verstockt
- Department of Human GeneticsLaboratory for Complex GeneticsKU LeuvenLeuvenBelgium
| | - Brecht Creyns
- Department of Microbiology and ImmunologyLaboratory of Clinical Immunology, KU LeuvenLeuvenBelgium
| | - Sophie Tops
- Department of Pharmaceutical and Pharmacological SciencesLaboratory for Therapeutic and Diagnostic Antibodies, KU Leuven LeuvenBelgium
| | - Gert Van Assche
- Department of Chronic Diseases, Metabolism and AgeingTranslational Research Center for Gastrointestinal Disorders (TARGID), KU LeuvenLeuvenBelgium,Department of Gastroenterology and HepatologyUniversity Hospitals Leuven, KU LeuvenLeuvenBelgium
| | - Ann Gils
- Department of Pharmaceutical and Pharmacological SciencesLaboratory for Therapeutic and Diagnostic Antibodies, KU Leuven LeuvenBelgium
| | - Jan L. Ceuppens
- Department of Microbiology and ImmunologyLaboratory of Clinical Immunology, KU LeuvenLeuvenBelgium
| | - Séverine Vermeire
- Department of Chronic Diseases, Metabolism and AgeingTranslational Research Center for Gastrointestinal Disorders (TARGID), KU LeuvenLeuvenBelgium,Department of Gastroenterology and HepatologyUniversity Hospitals Leuven, KU LeuvenLeuvenBelgium
| | - Marc Ferrante
- Department of Chronic Diseases, Metabolism and AgeingTranslational Research Center for Gastrointestinal Disorders (TARGID), KU LeuvenLeuvenBelgium,Department of Gastroenterology and HepatologyUniversity Hospitals Leuven, KU LeuvenLeuvenBelgium
| | - Christine Breynaert
- Department of Microbiology and ImmunologyLaboratory of Clinical Immunology, KU LeuvenLeuvenBelgium
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