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Nguyen AL, Gibson PR, Upton RN, Mould DR, Sparrow MP. Application of a Precision-Dosing Model to a Real-World Cohort of Patients on Infliximab Maintenance Therapy: Drug Usage and Cost Analysis. J Clin Pharmacol 2024; 64:399-409. [PMID: 37964618 DOI: 10.1002/jcph.2384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 11/12/2023] [Indexed: 11/16/2023]
Abstract
Precision-dosing models forecast infliximab doses to achieve targeted trough concentrations in patients with inflammatory bowel disease (IBD). These models have shown to reduce nonresponse and improve patient outcomes. We compared infliximab doses determined by iDOSE precision dosing with standard dosing, and the associated drug costs, in patients with IBD. In this retrospective study, patients with IBD treated with infliximab every 8 weeks at 5 mg/kg were included. An infliximab dose was named dose X if 3 previous infliximab doses, laboratory values including trough infliximab concentrations, and the patient's weight were recorded. The actual dose X was compared to an iDOSE-predicted dose X. Net drug use and costs were evaluated. A total of 174 patients-56% men; median age, 36 (interquartile range, 29-47) years; 135 with Crohn disease; and 31 with ulcerative colitis-were included, with 417 dose X recordings. Median prior infliximab therapy was 2 (0-4) years. Comparing actual dose X with predicted dose X, 52% and 32% of doses were subtherapeutic when aiming for trough concentrations of 5-10 and 3-7 μg/mL, respectively. Treatment costs increased by 102% and 29% for the 2 trough ranges, respectively. On multivariate regression analysis, subtherapeutic infliximab concentrations were associated with ulcerative colitis compared with Crohn disease (odds ratio, 9.81; 95% confidence interval, 1.28-75.40; P = .028) and predose X infliximab trough concentration [odds ratio, 0.07; 95% confidence interval, 0.03-0.15; P < .001]. Over half of maintenance infliximab drug doses were too low to achieve infliximab blood concentrations of 5 μg/mL or greater. While applying precision dosing may improve patient outcomes, drug costs could be considerably greater.
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Affiliation(s)
- Anke L Nguyen
- Department of Gastroenterology, Central Clinical School, Monash University and Alfred Health, Melbourne, Victoria, Australia
- Department of Gastroenterology, Monash Health, Melbourne, Australia
| | - Peter R Gibson
- Department of Gastroenterology, Central Clinical School, Monash University and Alfred Health, Melbourne, Victoria, Australia
| | - Richard N Upton
- Projections Research, Inc., Phoenixville, PA, USA
- University of South Australia, Adelaide, Australia
| | | | - Miles P Sparrow
- Department of Gastroenterology, Central Clinical School, Monash University and Alfred Health, Melbourne, Victoria, Australia
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Nigam GB, Chatten K, Sharara A, Al-Taweel T, Alharbi O, Elamin H, Al Awadhi S, Annese V, Limdi JK. Attitudes, perceptions and barriers in implementing therapeutic drug monitoring for anti-TNFs in inflammatory bowel disease: a survey from the Middle East. Therap Adv Gastroenterol 2024; 17:17562848241230902. [PMID: 38406794 PMCID: PMC10894550 DOI: 10.1177/17562848241230902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 01/17/2024] [Indexed: 02/27/2024] Open
Abstract
Background A growing body of evidence underscores the beneficial impact of therapeutic drug monitoring (TDM) on the efficacy and cost-effectiveness of anti-tumour necrosis factor (TNF) therapy in patients with inflammatory bowel disease (IBD). Objectives We surveyed clinician attitudes, perceptions and barriers related to TDM in IBD in the Middle East. Design A 15-question survey was distributed through national gastroenterological societies in five Middle Eastern countries (UAE, Saudi Arabia, Kuwait, Lebanon and Egypt). Methods Data on clinician characteristics, demographics, utilization patterns and obstacles related to the adoption of TDM with anti-TNFs were gathered. Logistic regression analysis was used to predict factors influencing the utilization of TDM. Results Among 211 respondents (82% male), 82% were consultants, 8% were physicians with an interest in gastroenterology (GI), and 6% were GI trainees. Of these, 152 met inclusion criteria, treating >5 IBD patients per month and ⩾1 with an anti-TNF per month. TDM was used in clinical practice by 78% (95% CI: 71-85) of respondents. TDM was utilized following the loss of response (LOR) in 93%, for primary non-response (PNR) in 40% and before restarting anti-TNF therapy after a drug holiday in 33% of respondents, while 34% used TDM proactively. No specific factors were associated with the use of TDM. Barriers to TDM use included cost (85%), time lag to results (71%) and lack of insurance reimbursement (65%). Overall knowledge of TDM (70%), interpretation and actioning of results (76%) or awareness of clinical guidelines (57%) were not perceived as barriers. If barriers were removed, 95% would use TDM more frequently; 93% for LOR, 60% for PNR, 50% when restarting after a drug holiday, and 54% would use TDM proactively. Conclusion Most gastroenterologists use TDM for LOR, with cost, time lag and insurance reimbursement being significant barriers. Addressing these barriers would increase the judicious use of reactive and proactive TDM to optimize anti-TNF therapy in IBD.
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Affiliation(s)
- Gaurav B. Nigam
- Translational Gastroenterology Unit, Nuffield Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Kelly Chatten
- Northern Care Alliance NHS Foundation Trust, Bury, UK
| | - Ala Sharara
- Division of Gastroenterology and Hepatology, American University of Beirut Medical Center, Beirut, Lebanon
- Duke University Medical Center, Durham, NC, USA
| | - Talal Al-Taweel
- Division of Gastroenterology, Department of Internal Medicine, Jaber Al-Ahmad Hospital, Ministries Area, Kuwait
| | | | | | | | - Vito Annese
- Fakeeh University Hospital, Dubai, United Arab Emirates
- Vita-Salute San Raffaele University, Milan, Italy
- IRCCS San Donato Polyclinic, Milan, Italy
| | - Jimmy K. Limdi
- Northern Care Alliance NHS Foundation Trust, Fairfield General Hospital, Rochdale Old Road, Bury, Greater Manchester BL9 7TD, UK
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
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Zitomersky N, Chi L, Liu E, Bray KR, Papamichael K, Cheifetz AS, Snapper SB, Bousvaros A, Silvester JA. Anti-infliximab antibodies and low infliximab levels correlate with drug discontinuation in pediatric inflammatory bowel disease. J Pediatr Gastroenterol Nutr 2024; 78:261-271. [PMID: 38374555 PMCID: PMC10883602 DOI: 10.1002/jpn3.12074] [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: 10/07/2023] [Revised: 10/11/2023] [Accepted: 10/13/2023] [Indexed: 02/21/2024]
Abstract
BACKGROUND Infliximab (IFX) use is limited by loss of response often due to the development of anti-IFX antibodies and low drug levels. METHODS We performed a single center prospective observational cohort study of pediatric and young adult subjects with inflammatory bowel disease (IBD) on IFX with over 3 years of follow-up. Infliximab levels (IFXL) and antibodies to infliximab (ATI) were measured throughout the study. Subjects were followed until IFX was discontinued. RESULTS We enrolled 219 subjects with IBD (184: Crohn's disease; 33: Ulcerative colitis; and 2 Indeterminant colitis; 84 female, median age 14.4 years, 37% on concomitant immunomodulator). Nine hundred and nineteen serum samples (mean 4.2 ± 2.1 per patient) were tested for IFXL and ATI. During the study, 31 (14%) subjects discontinued IFX. Sixty patients had ATI. Twenty-two of those 60 patients with ATI discontinued IFX; 14 of 31 patients who discontinued IFX had detectable ATI at study onset. The combination of ATI and IFXL < 5 µg/mL at study entry was associated with the highest risk of drug discontinuation (hazard ratios [HR] ATI 4.27 [p < 0.001] and IFXL < 5 µg/mL [HR]: 3.2 p = 0.001). Patients with IFXL 5-10 µg/mL had the lowest rate of discontinuation (6%). IFX dose escalation eliminated ATI in 21 of 60 subjects. CONCLUSIONS ATI is a strong predictor of needing to stop IFX use and inversely correlates with IFXL. Detection of ATI during therapeutic drug monitoring postinduction but also periodically during maintenance therapy identifies individuals who may benefit from IFX dose escalation and/or the addition of an immunomodulator, as these interventions may reduce or eliminate ATI.
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Affiliation(s)
- Naamah Zitomersky
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Boston Children’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Lisa Chi
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Boston Children’s Hospital, Boston, MA
| | - Enju Liu
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, MA
| | - Kurtis R. Bray
- Prometheus Laboratories Inc. San Diego, CA
- ProciseDx LLC, San Diego, CA
| | | | - Adam S. Cheifetz
- Harvard Medical School, Boston, MA
- Beth Israel Deaconess Medical Center, Boston, MA
| | - Scott B. Snapper
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Boston Children’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Division of Gastroenterology, Brigham and Women’s Hospital, Boston, MA
| | - Athos Bousvaros
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Boston Children’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Jocelyn A. Silvester
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Boston Children’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Beth Israel Deaconess Medical Center, Boston, MA
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Kim ES, Kim SK, Park DI, Kim HJ, Lee YJ, Koo JS, Kim ES, Yoon H, Lee JH, Kim JW, Shin SJ, Kim HW, Kim HS, Park YS, Kim YS, Kim TO, Lee J, Choi CH, Han DS, Chun J, Kim HS. Comparison of the Pharmacokinetics of CT-P13 Between Crohn's Disease and Ulcerative Colitis. J Clin Gastroenterol 2023; 57:601-609. [PMID: 35470308 DOI: 10.1097/mcg.0000000000001715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 03/20/2022] [Indexed: 12/10/2022]
Abstract
BACKGROUND We aimed to compare trough infliximab levels and the development of antidrug antibody (ADA) for 1 year between Crohn's disease (CD) and ulcerative colitis (UC) patients who were biologic-naive, and to evaluate their impact on clinical outcomes. METHODS This was a prospective, multicenter, observational study. Biologic-naive patients with moderate to severe CD or UC who started CT-P13, an infliximab biosimilar, therapy were enrolled. Trough drug and ADA levels were measured periodically for 1 year after CT-P13 initiation. RESULTS A total of 267 patients who received CT-P13 treatment were included (CD 168, UC 99). The rates of clinical remission (72% vs. 32.3%, P <0.001) at week 54 were significantly higher in CD than in UC. The median trough drug level (μg/mL) was significantly higher in CD than in UC up to week 14 (week 2, 18.7 vs. 14.7, P <0.001; week 6, 12.5 vs. 8.6, P <0.001; week 14, 3.4 vs. 2.5, P =0.001). The median ADA level (AU/mL) was significantly lower in CD than in UC at week 2 (6.3 vs. 6.5, P =0.046), week 30 (7.9 vs. 11.8, P =0.007), and week 54 (9.3 vs. 12.3, P =0.032). Development of ADA at week 2 [adjusted odds ratio (aOR)=0.15, P =0.026], initial C-reactive protein level (aOR=0.87, P =0.032), and CD over UC (aOR=1.92, P <0.001) were independent predictors of clinical remission at week 54. CONCLUSION Infliximab shows more favorable pharmacokinetics, including high drug trough and low ADA levels, in CD than in UC, which might result in better clinical outcomes for 1-year infliximab treatment in CD patients.
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Affiliation(s)
- Eun Soo Kim
- Department of Internal Medicine, Kyungpook National University, School of Medicine
| | - Sung Kook Kim
- Department of Internal Medicine, Kyungpook National University, School of Medicine
| | - Dong Il Park
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine
| | - Hyo Jong Kim
- Center for Crohn's and Colitis, Kyung Hee University Hospital
| | - Yoo Jin Lee
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu
| | - Ja Seol Koo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Ansan Hospital, Korea University College of Medicine, Ansan
| | - Eun Sun Kim
- Department of Internal Medicine, Korea University College of Medicine
| | - Hyuk Yoon
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam
| | - Ji Hyun Lee
- Digestive Endoscopic Center, Seoul Song Do Colorectal Hospital
| | - Ji Won Kim
- Department of Internal Medicine, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine
| | - Sung Jae Shin
- Department of Internal Medicine, Ajou University School of Medicine, Suwon
| | - Hyung Wook Kim
- Department of Internal Medicine, Pusan National University School of Medicine And Medical Research Institute
| | - Hyun-Soo Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju
| | - Young Sook Park
- Department of Internal Medicine, Eulji University School of Medicine, Eulji Hospital
| | - You Sun Kim
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine
| | - Tae Oh Kim
- Department of Internal Medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan
| | - Jun Lee
- Department of Internal Medicine, Chosun University, School of Medicine
| | - Chang Hwan Choi
- Department of Internal Medicine, College of Medicine, Chung-Ang University
| | - Dong Soo Han
- Department of Internal Medicine, Hanyang University College of Medicine, Guri, Korea
| | - Jaeyoung Chun
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul
| | - Hyun Soo Kim
- Department of Internal Medicine, Chonnam University Medical School, Gwangju
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Barrau M, Duprat M, Veyrard P, Tournier Q, Williet N, Phelip JM, Waeckel L, Cheifetz AS, Papamichael K, Roblin X, Paul S. A Systematic Review on the interest of Drug Tolerant assay in the monitoring of Inflammatory Bowel Disease. J Crohns Colitis 2022; 17:633-643. [PMID: 36301958 DOI: 10.1093/ecco-jcc/jjac164] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Indexed: 02/08/2023]
Abstract
Many patients with inflammatory bowel disease (IBD) are treated with anti-tumor necrosis factor (TNF) therapies, of which infliximab (IFX) is most commonly used. Loss of response (LOR) to anti-TNF therapy due to immunogenic failure accounts for 20% of subsequent medical intervention and is defined, using a drug sensitive assay, as low or undetectable concentration of drug with high titers of anti-drug antibodies (ADAb). We performed a systematic review to investigate the use of a drug tolerant assay during both induction and maintenance to monitor patients treated with anti-TNFs. After the search on PubMed, 90 publications were reviewed. Most ADAb detection methods are drug sensitive, cannot detect ADAb in the presence of drug, and therefore cannot be used close to drug administration, when the drug concentration is too high. To overcome this major limitation, several drug-tolerant techniques have been developed and will be discussed in this review. Using drug-tolerant assays ADAb against infliximab (IFX) or adalimumab (ADM) can be detected during induction and predict primary non-response or LOR. Drug sensitive assays do not allow detection of ADAb during the induction phase as IFX or ADM concentration is typically high.
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Affiliation(s)
- Mathilde Barrau
- Department of Gastroenterology, University Hospital of Saint Etienne, Saint Etienne, France
| | - Manon Duprat
- Department of Immunology, CIRI - Centre International de Recherche en Infectiologie, Team GIMAP, Univ Lyon, Université Claude Bernard Lyon 1, Inserm, U1111, CNRS, UMR530, CIC 1408 Vaccinology, F42023 Saint-Etienne, France
| | - Pauline Veyrard
- Department of Gastroenterology, University Hospital of Saint Etienne, Saint Etienne, France
| | - Quentin Tournier
- Department of Gastroenterology, University Hospital of Saint Etienne, Saint Etienne, France
| | - Nicolas Williet
- Department of Gastroenterology, University Hospital of Saint Etienne, Saint Etienne, France
| | - Jean Marc Phelip
- Department of Gastroenterology, University Hospital of Saint Etienne, Saint Etienne, France
| | - Louis Waeckel
- Department of Immunology, CIRI - Centre International de Recherche en Infectiologie, Team GIMAP, Univ Lyon, Université Claude Bernard Lyon 1, Inserm, U1111, CNRS, UMR530, CIC 1408 Vaccinology, F42023 Saint-Etienne, France
| | - Adam S Cheifetz
- Center for Inflammatory Bowel Disease, Beth Israel Deaconess Medical Center Instructor in Medicine, Harvard Medical School
| | - Konstantinos Papamichael
- Center for Inflammatory Bowel Disease, Beth Israel Deaconess Medical Center Instructor in Medicine, Harvard Medical School
| | - Xavier Roblin
- Department of Gastroenterology, University Hospital of Saint Etienne, Saint Etienne, France
| | - Stephane Paul
- Department of Immunology, CIRI - Centre International de Recherche en Infectiologie, Team GIMAP, Univ Lyon, Université Claude Bernard Lyon 1, Inserm, U1111, CNRS, UMR530, CIC 1408 Vaccinology, F42023 Saint-Etienne, France
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Han ZM, Elodie WH, Yan LH, Xu PC, Zhao XM, Zhi FC. Correlation Between Ultrasonographic Response and Anti-Tumor Necrosis Factor Drug Levels in Crohn's disease. Ther Drug Monit 2022; 44:659-664. [PMID: 35427284 DOI: 10.1097/ftd.0000000000000988] [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: 01/06/2022] [Accepted: 03/25/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Ultrasound is valuable in tight control algorithms for Crohn's disease (CD). However, the correlation between ultrasonographic response and anti-tumor necrosis factor (TNF) drug levels remains unknown. Elucidating this correlation would be helpful in optimizing the use of anti-TNF drugs. Thus, the authors aimed to investigate this correlation. METHODS Between June 2020 and June 2021, all patients with CD who completed anti-TNF induction therapy were retrospectively included. Ultrasound was performed at week 0 and week 14, and proactive therapeutic drug monitoring of anti-TNF drugs was performed at week 14. The receiver operating characteristic (ROC) curve was used in the correlation analysis. RESULTS Ninety-two patients (60 treated with infliximab and 32 with adalimumab) were included. At week 14, an ultrasonographic response was detected in 43 patients. Patients with ultrasonographic response had significantly higher median drug levels (5.9 mcg/mL for infliximab; 18.2 mcg/mL for adalimumab) than those without (0.9 mcg/mL for infliximab, P < 0.001; 4.8 mcg/mL for adalimumab, P < 0.001). The ROC curve showed a significant correlation between ultrasonographic response and anti-TNF drug levels (area under the curve = 0.79 for infliximab, P < 0.001; area under the curve = 0.86 for adalimumab, P < 0.001). The optimal cut-off values for infliximab and adalimumab correlated with ultrasonographic response were 5.0 and 10.5 mcg/mL, respectively. An incremental increase was observed in ultrasonographic response with higher anti-TNF drug levels. CONCLUSIONS Higher anti-TNF drug levels are associated with an increased likelihood of ultrasonographic response in patients with CD.
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Affiliation(s)
- Ze-Min Han
- Department of Gastroenterology, Institute of Gastroenterology of Guangdong Province, Guangdong Provincial Key Laboratory of Gastroenterology, Nanfang Hospital, Southern Medical University; and
| | - Welera Haissou Elodie
- Department of Gastroenterology, Institute of Gastroenterology of Guangdong Province, Guangdong Provincial Key Laboratory of Gastroenterology, Nanfang Hospital, Southern Medical University; and
| | - Li-Hua Yan
- Department of Ultrasound, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Pei-Chun Xu
- Department of Gastroenterology, Institute of Gastroenterology of Guangdong Province, Guangdong Provincial Key Laboratory of Gastroenterology, Nanfang Hospital, Southern Medical University; and
| | - Xin-Mei Zhao
- Department of Gastroenterology, Institute of Gastroenterology of Guangdong Province, Guangdong Provincial Key Laboratory of Gastroenterology, Nanfang Hospital, Southern Medical University; and
| | - Fa-Chao Zhi
- Department of Gastroenterology, Institute of Gastroenterology of Guangdong Province, Guangdong Provincial Key Laboratory of Gastroenterology, Nanfang Hospital, Southern Medical University; and
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Zeze K, Hirano A, Torisu T, Esaki M, Moriyama T, Umeno J, Kawasaki K, Fujioka S, Fuyuno Y, Matsuno Y, Kitazono T. Adding Thiopurine After Loss of Response to Infliximab Versus Early Combination in Treating Crohn's Disease: A Retrospective Study. Dig Dis Sci 2021; 66:3124-3131. [PMID: 32920717 DOI: 10.1007/s10620-020-06600-z] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 09/01/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Although combining thiopurine with infliximab (IFX) is considered to improve the clinical efficacy of IFX when treating Crohn's disease (CD), it also increases the risk of adverse events (AEs). We compared the efficacy and safety of delayed thiopurine addition after loss of response (LOR) to IFX with the efficacy and safety of an earlier combination of thiopurine and IFX. METHODS This retrospective study analyzed patients with CD who started IFX as a first-line biologic at Kyushu University Hospital between June 2002 and July 2018. Patients were assigned to either the early-combination (EC) group, who started IFX and thiopurine simultaneously, or the late-combination (LC) group, who were treated with IFX alone until they developed LOR. We compared the cumulative IFX continuation rates and AE incidence between the two groups. RESULTS One hundred seventy-six patients were enrolled in this study; 49 were enrolled in the EC group, and 127 were enrolled in the LC group. Disease activity at baseline did not significantly differ between the groups, nor did the cumulative IFX continuation rates differ between the groups (P = 0.30); however, the AE rate was significantly higher in the EC group than in the LC group (38.7% vs. 21.2%; P = 0.02). The severe AE rate was also higher in the EC group than in the LC group (18.3% vs 3.1%; P = 0.001). CONCLUSION Considering the risk-benefit balance, delayed addition of thiopurine after LOR to IFX might be an alternative strategy when using IFX to treat CD.
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Affiliation(s)
- Keizo Zeze
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Atsushi Hirano
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Takehiro Torisu
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Motohiro Esaki
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Tomohiko Moriyama
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Junji Umeno
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Keisuke Kawasaki
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Shin Fujioka
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yuta Fuyuno
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yuichi Matsuno
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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Elias ED, Bernstein CN, Singh H, Oketola A, Krishnan S, Targownik LE. Dose Augmentation of Tumor Necrosis Factor Inhibitors is Frequently Performed in Persons With Inflammatory Bowel Disease in the Absence of Objective Evidence of Active Inflammation. J Clin Gastroenterol 2021; 55:602-8. [PMID: 32694264 DOI: 10.1097/MCG.0000000000001391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 06/07/2020] [Indexed: 12/10/2022]
Abstract
BACKGROUND Antitumor necrosis factor (anti-TNF) dose augmentation is frequently utilized in the management of inflammatory bowel disease (IBD), yet the extent to which clinicians assess for objective markers of inflammation before using the strategy is unknown. AIMS To determine the incidence of anti-TNF dose augmentation and the frequency with which it is preceded by the objective assessment of IBD activity. MATERIALS AND METHODS All 23 prescribers of anti-TNF for IBD in Manitoba facilitated chart review of their adult anti-TNF users from 2005 to 2016. Time from anti-TNF initiation to dose augmentation was recorded for all previously biologic-naïve patients. The practices of 11 of 23 prescribers were audited in greater detail and the biochemical, imaging, and endoscopic investigations conducted in the 90-day preceding dose augmentation extracted. RESULTS A total of 838 patients met inclusion criteria; 70.4% had Crohn's disease, whereas 29.6% had ulcerative colitis or IBD unclassified. The median duration of follow-up was 22.6 [interquartile range (IQR), 10.3-43.2] months for adalimumab and 28.4 (IQR, 10.2-59.9) months for infliximab (P=0.01). The cumulative incidence of dose augmentation at 12 months was 32.9%. Dose augmentation occurred more often in ulcerative colitis than in Crohn's disease (hazard ratio, 1.83; IQR, 1.36-2.47). Overall, 70.7% of patients underwent some form of testing to assess the inflammatory burden before dose augmentation. Objective evidence of inflammation supporting dose augmentation was documented in only 24.7% of cases. CONCLUSIONS One third of previously biologic-naïve patients had anti-TNF doses increased within the first 12 months of treatment. Dose augmentation frequently occurred in the absence of objective evidence of inflammatory disease activity.
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Parrish RH. Biosimilar Interchangeability and Emerging Treatment Strategies for Inflammatory Bowel Diseases: A Commentary. Gastroenterology Insights 2021; 12:293-301. [DOI: 10.3390/gastroent12030026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This commentary summarizes a collection of key references published within the last ten years, and identifies pharmacologic research directions to improve treatment access and success through greater biosimilar or “follow-on” biologic utilization combined with other targeted small molecule agents that possess unique pathophysiologic mechanisms for inflammatory bowel diseases (IBD) in adult and pediatric patients. Since they are not identical to the originator or reference biologic agent, all biosimilars are not generically equivalent. However, in the US and other countries, they are considered therapeutically interchangeable if the manufacturer has demonstrated no clinically meaningful differences from the reference product. Comparisons of different clinical initiation and switching scenarios are discussed with reference to interchangeability, immunogenicity, nocebo effect, cost effectiveness, and time courses for discontinuation rates.
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Strik AS, Löwenberg M, Mould DR, Berends SE, Ponsioen CI, van den Brande JMH, Jansen JM, Hoekman DR, Brandse JF, Duijvestein M, Gecse KB, de Vries A, Mathôt RA, D'Haens GR. Efficacy of dashboard driven dosing of infliximab in inflammatory bowel disease patients; a randomized controlled trial. Scand J Gastroenterol 2021; 56:145-154. [PMID: 33290108 DOI: 10.1080/00365521.2020.1856405] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Loss of response (LOR) to infliximab (IFX) remains a challenge in the management of inflammatory bowel diseases (IBD). Proactive dosing strategies to achieve and maintain predefined IFX trough levels (TL) may prevent LOR. We aimed to investigate the efficacy of dashboard driven IFX dosing compared to standard dosing in a prospective trial in IBD patients. METHODS In this multicentre 1:1 'PRECISION' trial, we randomized IBD patients in clinical remission (Harvey Bradshaw Index ≤4 for Crohn's disease (CD) or a partial Mayo score ≤2 for ulcerative colitis (UC)) receiving IFX maintenance treatment. The precision group (PG) received IFX dosing guided by a Bayesian pharmacokinetic model, aiming to achieve and maintain a TL of 3 µg/ml by treatment (de)escalation as indicated by the dashboard. Patients in the control group (CG) continued treatment without dose adaptations. The primary endpoint was the proportion of patients in sustained clinical remission after 1 year. RESULTS Eighty patients were enrolled (66 CD, 14 UC), and the median [interquartile range] age was 37 years [27-51]). After one year, 28/32 (88%) of patients in the PG were in sustained clinical remission versus 25/39 (64%) in the CG (p = .017). PG patients had lower median faecal calprotectin levels after 1 year (p = .031), whereas no significant differences in median CRP levels were found. CONCLUSION We demonstrated that the use of a Bayesian dashboard for IFX dosing in maintenance treatment for IBD reduced the incidence of LOR compared to standard dosing. Precision dosing also resulted in lower FCP levels. CLINICALTRIALS.GOV NUMBER NCT02453776.
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Affiliation(s)
- Anne S Strik
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location AMC , Amsterdam, The Netherlands
| | - Mark Löwenberg
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location AMC , Amsterdam, The Netherlands
| | | | - Sophie E Berends
- Department of Hospital Pharmacy, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Cyriel I Ponsioen
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location AMC , Amsterdam, The Netherlands
| | - Jan M H van den Brande
- Department of Gastroenterology and Hepatology, Tergooi Hospital, Hilversum, The Netherlands
| | - Jeroen M Jansen
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Daniël R Hoekman
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location AMC , Amsterdam, The Netherlands
| | - Johannan F Brandse
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location AMC , Amsterdam, The Netherlands
| | - Marjolijn Duijvestein
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location AMC , Amsterdam, The Netherlands
| | - Krisztina B Gecse
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location AMC , Amsterdam, The Netherlands
| | | | - Ron A Mathôt
- Department of Hospital Pharmacy, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Geert R D'Haens
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location AMC , Amsterdam, The Netherlands
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11
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Grisic AM, Eser A, Huisinga W, Reinisch W, Kloft C. Quantitative relationship between infliximab exposure and inhibition of C-reactive protein synthesis to support inflammatory bowel disease management. Br J Clin Pharmacol 2020; 87:2374-2384. [PMID: 33184852 DOI: 10.1111/bcp.14648] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 10/13/2020] [Accepted: 11/06/2020] [Indexed: 01/11/2023] Open
Abstract
AIM Quantitative and kinetic insights into the drug exposure-disease response relationship might enhance our knowledge on loss of response and support more effective monitoring of inflammatory activity by biomarkers in patients with inflammatory bowel disease (IBD) treated with infliximab (IFX). This study aimed to derive recommendations for dose adjustment and treatment optimisation based on mechanistic characterisation of the relationship between IFX serum concentration and C-reactive protein (CRP) concentration. METHODS Data from an investigator-initiated trial included 121 patients with IBD during IFX maintenance treatment. Serum concentrations of IFX, antidrug antibodies (ADA), CRP, and disease-related covariates were determined at the mid-term and end of a dosing interval. Data were analysed using a pharmacometric nonlinear mixed-effects modelling approach. An IFX exposure-CRP model was generated and applied to evaluate dosing regimens to achieve CRP remission. RESULTS The generated quantitative model showed that IFX has the potential to inhibit up to 72% (9% relative standard error [RSE]) of CRP synthesis in a patient. IFX concentration leading to 90% of the maximum CRP synthesis inhibition was 18.4 μg/mL (43% RSE). Presence of ADA was the most influential factor on IFX exposure. With standard dosing strategy, ≥55% of ADA+ patients experienced CRP nonremission. Shortening the dosing interval and co-therapy with immunomodulators were found to be the most beneficial strategies to maintain CRP remission. CONCLUSIONS With the generated model we could for the first time establish a robust relationship between IFX exposure and CRP synthesis inhibition, which could be utilised for treatment optimisation in IBD patients.
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Affiliation(s)
- Ana-Marija Grisic
- Department of Clinical Pharmacy & Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Germany.,Graduate Research Training Program PharMetrX, Germany
| | - Alexander Eser
- Department for Gastroenterology and Hepatology, Medical University of Vienna, Austria
| | | | - Walter Reinisch
- Department for Gastroenterology and Hepatology, Medical University of Vienna, Austria
| | - Charlotte Kloft
- Department of Clinical Pharmacy & Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Germany
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12
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Kimura K, Yoshida A, Katagiri F, Takayanagi R, Yamada Y. Prediction of treatment failure during infliximab induction therapy in inflammatory bowel disease patients based on pharmacokinetic and pharmacodynamic modeling. Eur J Pharm Sci 2020; 150:105317. [PMID: 32205229 DOI: 10.1016/j.ejps.2020.105317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 02/27/2020] [Accepted: 03/19/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND In infliximab (IFX) treatment for Crohn's disease (CD) and ulcerative colitis (UC), it is difficult to predict treatment failure during the induction phase. In the present study for optimal IFX treatment, we attempted to estimate serum IFX concentration and clinical response in individual patients during the induction phase to predict the indication of therapeutic effect and the possibility of treatment failure in the maintenance phase. METHODS We estimated pharmacokinetic and pharmacodynamic (PK/PD) parameters and predicted the serum IFX concentration and clinical response using a PK/PD model and Markov chain Monte Carlo Bayesian analysis method during the induction phase. Then, we determined whether the indication of therapeutic effect between predicted and observed clinical response were matched during the maintenance phase. RESULTS Data obtained from 15 patients were analyzed. The correlation between predicted and observed values of serum IFX concentration (Pearson product-moment correlation coefficient, 0.700; P < 0.0001, n = 68) and clinical response of CD patients (0.790; P < 0.0001, n = 25) and UC patients (0.702; P = 0.0004, n = 21) were significantly high. The indication of therapeutic effect at the final time point of each patient (from day 115 to day 203) were successfully predicted in 14 of 15 patients (93.3%). CONCLUSIONS This study presents prediction of serum IFX concentration and clinical response in individual patients during induction therapy, with presumption of the indication of therapeutic effect and the treatment failure in the maintenance phase. Our results show the possibility of optimizing IFX therapy during the induction phase.
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13
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Winter DA, Joosse ME, de Wildt SN, Taminiau J, de Ridder L, Escher JC. Pharmacokinetics, Pharmacodynamics, and Immunogenicity of Infliximab in Pediatric Inflammatory Bowel Disease: A Systematic Review and Revised Dosing Considerations. J Pediatr Gastroenterol Nutr 2020; 70:763-76. [PMID: 32443029 DOI: 10.1097/MPG.0000000000002631] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Infliximab (IFX), a monoclonal antibody directed against tumor necrosis factor alpha is a potent treatment option for inflammatory bowel disease (IBD). Dosing regimens in children are extrapolated from adult data using a fixed, weight-based dose, which is often not adequate. While clinical trials have focused on safety and efficacy, there is limited data on pharmacokinetic characteristics and immunogenicity of IFX in children. The objective was to provide a systematic overview of current literature on pharmacokinetic and immunogenicity of IFX in children with IBD, to assess the validity of current adult to pediatric dosing extrapolation. METHODS A literature search identified publications up to October 2018. Eligibility criteria were study population consisting of children and/or adolescents with IBD, report of IFX trough levels and/or antibodies-to IFX, full text article or abstract, article in English, and original data. RESULTS Initial electronic search yielded 2360 potentially relevant articles, with 1831 remaining after removal of duplicates. An additional search yielded another 202 potentially relevant articles. Of the 2033 retrieved articles, 2000 articles were excluded based on title, abstract, or eligibility criteria. Clearance of IFX was increased in young children and children with extensive disease, leading to lower trough levels after extrapolated dosing of 5 mg/kg, antibodies-to IFX emergence, and subsequent reduced efficacy. CONCLUSIONS Adult to pediatric weight-based dosing extrapolation is often inadequate. We provide several considerations for optimal dosing of IFX in children and adolescents with IBD.
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14
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Patel RN, Nigam GB, Jatale RG, Desai D, Makharia G, Ahuja V, Limdi JK. An Indian national survey of therapeutic drug monitoring with anti-tumor necrosis (TNF) medications in inflammatory bowel disease. Indian J Gastroenterol 2020; 39:176-185. [PMID: 32483692 PMCID: PMC7297832 DOI: 10.1007/s12664-020-01047-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 04/27/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Evidence supports therapeutic drug monitoring (TDM) in improving efficacy and cost-effectiveness of anti-TNF therapy in inflammatory bowel disease (IBD). Data on perceptions and barriers to TDM use are limited and no data are available from India. Our objective was to assess clinicians' attitudes and barriers to TDM use in IBD. METHODS A 16-question survey was distributed to members of the Indian Society of Gastroenterology. Information on clinician characteristics, demographics, use and barriers towards TDM with anti-TNFs was collected. Logistic regression was used to predict factors influencing TDM use. RESULTS Two hundred and forty-two respondents participated (92.5% male); 83% were consultant gastroenterologists. Of 104 respondents meeting inclusion criteria (treating > 5 IBD patients and at least 1 with an anti-TNF per month), complete responses were available for 101 participants. TDM was utilized by 20% (n = 20) of respondents. Of them, 89.5% (n = 17) used TDM for secondary loss of response; 73.7% (n = 14) for primary non-response and 5.3% (n = 1) proactively. Barriers to TDM use were cost (71.2%), availability (67.8%), time lag in results (58.7%) and the perception that TDM is time-consuming (45.7%). Clinicians treating > 30 IBD patients were more likely to check TDM (OR = 4.9, p = 0.02). Of 81 respondents not using TDM, 97.5% (n = 79) would do so if all the barriers were removed. CONCLUSION Significant barriers to TDM use were availability, cost and time lag for results. If these barriers were removed, almost all the clinicians would use TDM at least reactively and 25% would use proactively. There is an urgent need to address these barriers and optimize anti-TNF therapy for optimal outcomes.
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Affiliation(s)
| | | | - Raj G Jatale
- Department of Bio-Statistics, P D Hinduja Hospital, Mumbai, 400 016, India
| | | | - Govind Makharia
- The All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Vineet Ahuja
- The All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Jimmy K Limdi
- The Pennine Acute Hospitals NHS Trust, Manchester Academic Health Sciences, University of Manchester, Manchester, UK.
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15
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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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16
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Nigam GB, Nayeemuddin S, Kontopantelis E, Hayee B, Limdi JK. UK National Survey of Gastroenterologists' attitudes and barriers toward therapeutic drug monitoring of anti-TNF therapy in inflammatory bowel disease. Frontline Gastroenterol 2020; 12:22-29. [PMID: 33493247 PMCID: PMC7802494 DOI: 10.1136/flgastro-2019-101372] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 12/27/2019] [Accepted: 01/07/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Evidence supports use of therapeutic drug monitoring (TDM) in improving efficacy and cost-effectiveness of anti-tumour necrosis factor (TNF) therapy in inflammatory bowel disease (IBD). Our objective was to assess attitudes and barriers towards TDM use with anti-TNF's in the UK. METHODS A 17-question survey was distributed to members of the British Society of Gastroenterology by email. RESULTS Of 243 respondents (51.6% male), 237 respondents met inclusion criteria. Of these, 46% were consultants (gastroenterologist, GI), 39.2% IBD nurse specialists (clinical nurse specialists, CNS), 14.8% registrars. TDM is used by 96.9% for secondary loss of response; 72.5% for primary non-response and 54.1% used TDM proactively. Barriers were time lag in receiving results (49.8%), lack of awareness of guidelines (46.4%) and cost (29.9%). Clinicians working at a teaching hospital (OR 2.6, 95% CI 0.71 to 9.8), IBD CNS and GI registrars (OR 2.6, 95% CI 0.7 to 10 and OR 1.5, 95% CI 0.3 to 7.2, respectively) were more likely to use TDM. Clinicians practising for >20 years (OR 4.1, 95% CI 0.4 to 41.8) and a large volume IBD practice (>50% IBD patients per month) were more likely to use TDM (OR 45.7, 95% CI 7.5 to 275). Proactive TDM, was more likely to be used in tertiary care (OR 2.25, 95% CI 0.84 to 6.1), IBD CNS (OR 1.2, 95% CI 0.7 to 2.1) and clinicians managing >50% IBD patients per month (OR 10.8, 95% CI 1.3 to 90.3). Clinicians with 5-9 years of experience in practice were more likely to use proactive TDM (OR 2.6 and CI 1.04 to 6.4). CONCLUSION Validation of point of care and lower cost assays, reduced time lag from test to result, lower cost of testing and dissemination of current recommendations may further optimise treatment strategies.
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Affiliation(s)
- Gaurav B Nigam
- Gastroenterology, Pennine Acute Hospitals NHS Trust, Manchester, UK
| | | | - Evangelos Kontopantelis
- Division of Informatics, Imaging & Data Sciences; Faculty of Medicine, Biology & Health, The University of Manchester, Manchester, UK
| | - Bu'Hussain Hayee
- Gastroenterology, King's College Hospital NHS Foundation Trust, London, UK,Gastroenterology, King's College London, London, UK
| | - Jimmy K Limdi
- Gastroenterology, Pennine Acute Hospitals NHS Trust, Manchester, UK,Gastroenterology, The University of Manchester, Manchester, UK
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17
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Elias ED, Targownik LE, Singh H, Bernstein CN. A Population-Based Study of Combination vs Monotherapy of Anti-TNF in Persons With IBD. Inflamm Bowel Dis 2020; 26:150-157. [PMID: 31340002 DOI: 10.1093/ibd/izz148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Few data exist about the utilization of combination therapy (anti-tumor necrosis factor [anti-TNF] plus immunosuppressives) in clinical practice. We assessed the prevalence and predictors of combination therapy use vs anti-TNF monotherapy in inflammatory bowel disease (IBD) in the Canadian province of Manitoba. METHODS All 23 prescribers of anti-TNF medications for IBD in Manitoba facilitated chart review of their comprehensive lists of adult anti-TNF patients from 2005 to 2015. Subjects were stratified by year of first anti-TNF exposure. Patient, disease, and prescriber factors influencing combination therapy use were explored. RESULTS A total of 774 patients met inclusion criteria. Seventy-one point one percent had Crohn's disease (CD), 28.3% had ulcerative colitis (UC), and 0.6% had IBD unclassified; 45.3% received combination therapy, with no difference between CD and UC. Crohn's disease subjects receiving combination therapy were more likely to have penetrating or perianal disease (56.9% vs 42.8%; P = 0.001) and less likely to have had previous IBD-related surgeries (36.2% vs 46.2%; P = 0.02). The median age at diagnosis and at anti-TNF initiation was lower among combination therapy users. Adalimumab users were as likely as infliximab users to receive combination therapy but persisted with treatment for a shorter time. The proportion of new anti-TNF users receiving combination therapy did not change over time (P = 0.43). There was substantial variation in combination therapy use between prescribers (P = 0.002). The most frequently encountered reasons for avoiding combination therapy were previous intolerance or ineffectiveness of immunosuppressive monotherapy. CONCLUSION Use of combination therapy has remained unchanged over time despite the publication of high-quality data supporting its efficacy over anti-TNF monotherapy.
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Affiliation(s)
- Evan D Elias
- Section of Gastroenterology, Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,University of Manitoba IBD Clinical and Research Centre, Winnipeg, Manitoba, Canada
| | - Laura E Targownik
- Section of Gastroenterology, Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,University of Manitoba IBD Clinical and Research Centre, Winnipeg, Manitoba, Canada
| | - Harminder Singh
- Section of Gastroenterology, Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,University of Manitoba IBD Clinical and Research Centre, Winnipeg, Manitoba, Canada
| | - Charles N Bernstein
- Section of Gastroenterology, Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,University of Manitoba IBD Clinical and Research Centre, Winnipeg, Manitoba, Canada
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18
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Gurram B, Patel AS. Recent advances in understanding and managing pediatric inflammatory bowel disease. F1000Res 2019; 8. [PMID: 31885858 PMCID: PMC6913196 DOI: 10.12688/f1000research.19609.1] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2019] [Indexed: 12/07/2022] Open
Abstract
The landscape of pediatric inflammatory bowel disease is rapidly evolving. The therapeutic advances seen in the adult arena are rapidly being adopted by pediatric gastroenterologists and evaluated in both controlled trials and real-world experience. Though anti-tumor necrosis factor agents have been the primary therapy over the last decade, recently there has been an expansion of therapeutic targets and alternative mechanism of action drugs with a focus on individualized and personalized therapy. By reviewing epidemiology, pathophysiology, and goals of treatment, we hope to frame the discussion of current and novel therapeutics for the pediatric gastroenterologist. As scientific discovery continues to push the envelope in defining our understanding of pediatric inflammatory bowel disease, the current era of therapeutics gives us hope that a cure may be realized soon.
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Affiliation(s)
- Bhaskar Gurram
- University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Ashish S. Patel
- University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
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19
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Feng T, Chen B, Ungar B, Qiu Y, Zhang S, He J, Lin S, He Y, Zeng Z, Ben-Horin S, Chen M, Mao R. Association of Infliximab Levels With Mucosal Healing Is Time-Dependent in Crohn's Disease: Higher Drug Exposure Is Required Postinduction Than During Maintenance Treatment. Inflamm Bowel Dis 2019; 25:1813-1821. [PMID: 30934050 DOI: 10.1093/ibd/izz061] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 11/16/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Infliximab levels have been reported to be associated with mucosal healing (MH) in Crohn's disease (CD). However, whether the association differs between postinduction (week 14) and maintenance (week 30) has seldom been investigated. We aimed to analyze the association between serum infliximab trough levels and MH at the 2 different time points. METHODS A retrospective study of CD patients treated with infliximab in a tertiary referral center between January 2012 and May 2018 was conducted. MH was defined as absence of ulceration by endoscopy. Correlations between infliximab level and MH were investigated at 2 specific time points, weeks 14 and 30. RESULTS Median infliximab levels were higher in patients with MH than those without at weeks 14 (7.5 vs 1.5 μg/mL; P < 0.001) and 30 (5.9 vs 0.5 μg/mL; P < 0.001). The median levels in patients with MH at week 14 were higher than at week 30 (7.5 vs 5.9 μg/mL; P < 0.05). Multivariate analysis showed that infliximab level was independently associated with MH (both P < 0.001 at weeks 14 and 30). Infliximab level above 4.85 μg/mL and 2.85 μg/mL identified patients with MH at week 14 (area under the curve [AUC], 0.796; P < 0.001) and week 30 (AUC, 0.780; P < 0.001) with 80% specificity. The rates of MH reached a plateau (>85%) when infliximab levels were above 10 and 6 μg/mL at weeks 14 and 30, respectively. CONCLUSIONS Infliximab levels correlated with MH at weeks 14 and 30 in CD patients. Higher levels might be required to achieve MH at postinduction than during maintenance treatment.
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Affiliation(s)
- Ting Feng
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China
| | - Baili Chen
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China
| | - Bella Ungar
- Department of Gastroenterology, Sheba Medical Center & Sackler School of Medicine, Tel-Aviv University, Tel Hashomer, Israel
| | - Yun Qiu
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China
| | - Shenghong Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China
| | - Jinshen He
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China
| | - Sinan Lin
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China
| | - Yao He
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China
| | - Zhirong Zeng
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China
| | - Shomron Ben-Horin
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China.,Department of Gastroenterology, Sheba Medical Center & Sackler School of Medicine, Tel-Aviv University, Tel Hashomer, Israel
| | - Minhu Chen
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China
| | - Ren Mao
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China.,Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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20
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Papamichael K, Cheifetz AS, Melmed GY, Irving PM, Casteele NV, Kozuch PL, Raffals LE, Baidoo L, Bressler B, Devlin SM, Jones J, Kaplan GG, Sparrow MP, Velayos FS, Ullman T, Siegel CA. Appropriate Therapeutic Drug Monitoring of Biologic Agents for Patients With Inflammatory Bowel Diseases. Clin Gastroenterol Hepatol 2019; 17:1655-1668.e3. [PMID: 30928454 PMCID: PMC6661210 DOI: 10.1016/j.cgh.2019.03.037] [Citation(s) in RCA: 192] [Impact Index Per Article: 38.4] [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: 10/23/2018] [Revised: 02/24/2019] [Accepted: 03/24/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Therapeutic drug monitoring (TDM) is widely available for biologic therapies in patients with inflammatory bowel disease (IBD). We reviewed current data and provided expert opinion regarding the clinical utility of TDM for biologic therapies in IBD. METHODS We used a modified Delphi method to establish consensus. A comprehensive literature review was performed regarding the use of TDM of biologic therapy in IBD and presented to international IBD specialists. Subsequently, 28 statements on the application of TDM in clinical practice were rated on a scale of 1 to 10 (1 = strongly disagree and 10 = strongly agree) by each of the panellists. Statements were accepted if 80% or more of the participants agreed with a score ≥7. The remaining statements were discussed and revised based on the available evidence followed by a second round of voting. RESULTS The panel agreed on 24 (86%) statements. For anti-tumor necrosis factor (anti-TNF) therapies, proactive TDM was found to be appropriate after induction and at least once during maintenance therapy, but this was not the case for the other biologics. Reactive TDM was appropriate for all agents both for primary non-response and secondary loss of response. The panellists also agreed on several statements regarding TDM and appropriate drug and anti-drug antibody (ADA) concentration thresholds for biologics in specific clinical scenarios. CONCLUSION Consensus was achieved towards the utility of TDM of biologics in IBD, particularly anti-TNF therapies. More data are needed especially on non-anti-TNF biologics to further define optimal drug concentration and ADA thresholds as these can vary depending on the therapeutic outcomes assessed.
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Affiliation(s)
| | | | - Gil Y. Melmed
- Cedars-Sinai Medical Center, Los Angeles, California
| | | | | | | | | | | | | | | | | | | | | | | | - Thomas Ullman
- Montefiore Medical Center/Albert Einstein College Medicine, Bronx, NY
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21
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Ooi CJ, Hilmi I, Banerjee R, Chuah SW, Ng SC, Wei SC, Makharia GK, Pisespongsa P, Chen MH, Ran ZH, Ye BD, Park DI, Ling KL, Ong D, Ahuja V, Goh KL, Sollano J, Lim WC, Leung WK, Ali RAR, Wu DC, Ong E, Mustaffa N, Limsrivilai J, Hisamatsu T, Yang SK, Ouyang Q, Geary R, De Silva JH, Rerknimitr R, Simadibrata M, Abdullah M, Leong RWL. Best practices on immunomodulators and biologic agents for ulcerative colitis and Crohn's disease in Asia. J Gastroenterol Hepatol 2019; 34:1296-1315. [PMID: 30848854 DOI: 10.1111/jgh.14648] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [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: 12/13/2018] [Revised: 02/05/2019] [Accepted: 03/02/2019] [Indexed: 02/05/2023]
Abstract
The Asia-Pacific Working Group on Inflammatory Bowel Disease was established in Cebu, Philippines, under the auspices of the Asia-Pacific Association of Gastroenterology with the goal of improving inflammatory bowel disease care in Asia. This consensus is carried out in collaboration with Asian Organization for Crohn's and Colitis. With biologic agents and biosimilars becoming more established, it is necessary to conduct a review on existing literature and establish a consensus on when and how to introduce biologic agents and biosimilars in conjunction with conventional treatments for ulcerative colitis and Crohn's disease in Asia. These statements also address how pharmacogenetics influences the treatments of ulcerative colitis and Crohn's disease and provides guidance on response monitoring and strategies to restore loss of response. Finally, the review includes statements on how to manage treatment alongside possible hepatitis B and tuberculosis infections, both common in Asia. These statements have been prepared and voted upon by members of inflammatory bowel disease workgroup employing the modified Delphi process. These statements do not intend to be all-encompassing, and future revisions are likely as new data continue to emerge.
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Affiliation(s)
- Choon Jin Ooi
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.,Duke-NUS Medical School, Singapore
| | - Ida Hilmi
- Faculty of Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Rupa Banerjee
- Asian Institute of Gastroenterology, New Delhi, India
| | | | - Siew Chien Ng
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Shu Chen Wei
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Govind K Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | | | - Min Hu Chen
- Division of Gastroenterology, The First University Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhi Hua Ran
- Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Byong Duk Ye
- Department of Gastroenterology and IBD Center, University of Ulsan College of Medicine, Ulsan, Korea
| | - Dong Il Park
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | | | - David Ong
- Division of Gastroenterology & Hepatology, University Medicine Cluster, National University Hospital of Singapore, Singapore
| | - Vineet Ahuja
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Khean Lee Goh
- University of Malaya Specialist Centre, Kuala Lumpur, Malaysia
| | - Jose Sollano
- Department of Medicine, University of Santo Tomas, Manila, Philippines
| | - Wee Chian Lim
- Department of Gastroenterology & Hepatology, Tan Tock Seng Hospital, Singapore
| | - Wai Keung Leung
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Hong Kong, Hong Kong
| | | | - Deng Chyang Wu
- Department of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Evan Ong
- Department of Medicine, University of Santo Tomas, Manila, Philippines
| | - Nazri Mustaffa
- Department of Internal Medicine, School of Medical Sciences, Health Campus, Universiti Sains, George Town, Malaysia
| | - Julajak Limsrivilai
- Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Tadakazu Hisamatsu
- The Third Department of Internal Medicine, Kyorin University School of Medicine, Mitaka, Japan
| | - Suk Kyun Yang
- Department of Gastroenterology, University of Ulsan College of Medicine, Ulsan, Korea
| | - Qin Ouyang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Richard Geary
- Department of Medicine, University of Otago, Christchurch, Christchurch, New Zealand
| | | | | | - Marcellus Simadibrata
- Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Depok, Indonesia
| | - Murdani Abdullah
- Division of Gastroenterology, Department of Internal Medicine, Dr Cipto Mangankusumo National Hospital, Central Jakarta, Indonesia
| | - Rupert W L Leong
- Gastroenterology and Liver Services, Concord Hospital, Sydney, New South Wales, Australia
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22
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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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23
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Ooi CJ, Hilmi I, Banerjee R, Chuah SW, Ng SC, Wei SC, Makharia GK, Pisespongsa P, Chen MH, Ran ZH, Ye BD, Park DI, Ling KL, Ong D, Ahuja V, Goh KL, Sollano J, Lim WC, Leung WK, Ali RAR, Wu DC, Ong E, Mustaffa N, Limsrivilai J, Hisamatsu T, Yang SK, Ouyang Q, Geary R, De Silva JH, Rerknimitr R, Simadibrata M, Abdullah M, Leong RW. Best practices on immunomodulators and biologic agents for ulcerative colitis and Crohn's disease in Asia. Intest Res 2019; 17:285-310. [PMID: 31146509 PMCID: PMC6667368 DOI: 10.5217/ir.2019.00026] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 04/15/2019] [Indexed: 02/07/2023] Open
Abstract
The Asia-Pacific Working Group on inflammatory bowel disease (IBD) was established in Cebu, Philippines, under the auspices of the Asian Pacific Association of Gastroenterology with the goal of improving IBD care in Asia. This consensus is carried out in collaboration with Asian Organization for Crohn’s and Colitis. With biologic agents and biosimilars becoming more established, it is necessary to conduct a review on existing literature and establish a consensus on when and how to introduce biologic agents and biosimilars in the conjunction with conventional treatments for ulcerative colitis (UC) and Crohn’s disease (CD) in Asia. These statements also address how pharmacogenetics influence the treatments of UC and CD and provide guidance on response monitoring and strategies to restore loss of response. Finally, the review includes statements on how to manage treatment alongside possible hepatitis B and tuberculosis infections, both common in Asia. These statements have been prepared and voted upon by members of IBD workgroup employing the modified Delphi process. These statements do not intend to be all-encompassing and future revisions are likely as new data continue to emerge.
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Affiliation(s)
- Choon Jin Ooi
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | | | - Rupa Banerjee
- Asian Institute of Gastroenterology, New Delhi, India
| | | | - Siew Chien Ng
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Shu Chen Wei
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Govind K Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Pises Pisespongsa
- Gastroenterology and Hepatology, Bumrungrad International University, Bangkok, Thailand
| | - Min Hu Chen
- Division of Gastroenterology, The First University Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhi Hua Ran
- Department of Gastroenterology and Hepatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Byong Duk Ye
- Department of Gastroenterology and IBD Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Il Park
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | | | - David Ong
- Division of Gastroenterology and Hepatology, National University Hospital of Singapore, University Medicine Cluster, Singapore
| | - Vineet Ahuja
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Khean Lee Goh
- University of Malaya Specialist Centre, Kuala Lumpur, Malaysia
| | - Jose Sollano
- Department of Medicine, University of Santo Tomas, Manila, Philippines
| | - Wee Chian Lim
- Department of Gastroenterology and Hepatology, Tan Tock Seng Hospital, Singapore
| | - Wai Keung Leung
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Hong Kong, Hong Kong
| | - Raja Affendi Raja Ali
- Faculty of Medicine, UKM Medical and Specialist Centres, The National University of Malaysia, Kuala Lumpur, Malaysia
| | - Deng Chyang Wu
- Department of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Evan Ong
- Department of Medicine, University of Santo Tomas, Manila, Philippines
| | - Nazri Mustaffa
- Department of Internal Medicine, School of Medical Sciences, Health Campus, Sains University, Kubang Kerian, Malaysia
| | - Julajak Limsrivilai
- Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Tadakazu Hisamatsu
- The Third Department of Internal Medicine, Kyorin University School of Medicine, Mitaka, Japan
| | - Suk Kyun Yang
- Department of Gastroenterology, University of Ulsan College of Medicine, Seoul, Korea
| | - Qin Ouyang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Richard Geary
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | | | | | - Marcellus Simadibrata
- Department of Internal Medicine, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - Murdani Abdullah
- Division of Gastroenterology, Department of Internal Medicine, Cipto Mangunkusumo National Hospital, Jakarta, Indonesia
| | - Rupert Wl Leong
- Gastroenterology and Liver Services, Concord Hospital, Sydney, Australia
| | -
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
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24
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Edlund H, Grisic A, Steenholdt C, Ainsworth MA, Brynskov J, Huisinga W, Kloft C. Absence of Relationship Between Crohn's Disease Activity Index or C-Reactive Protein and Infliximab Exposure Calls for Objective Crohn's Disease Activity Measures for the Evaluation of Treatment Effects at Treatment Failure. Ther Drug Monit 2019; 41:235-42. [DOI: 10.1097/ftd.0000000000000590] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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25
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Orfanoudaki E, Gazouli M, Foteinogiannopoulou K, Theodoraki E, Legaki E, Romanos I, Mouzas I, Koutroubakis IE. Infliximab trough levels are decreasing over time in patients with inflammatory bowel disease on maintenance treatment with infliximab. Eur J Gastroenterol Hepatol 2019; 31:187-91. [PMID: 30543573 DOI: 10.1097/MEG.0000000000001332] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Infliximab trough levels (IFX-TLs) and antibodies to infliximab (ATIs) have been suggested as useful markers for the optimization of treatment in inflammatory bowel disease (IBD). We aimed to estimate the patterns over time of IFX-TLs and ATIs in IBD patients on maintenance treatment with IFX. METHODS Two different measurements of IFX-TLs and ATIs were performed (ELISA; Eagle BioSciences) at a 10-month interval using serum samples of consecutive patients on maintenance treatment with IFX. Certain biomarkers [hemoglobin, erythrocyte sedimentation rate, C-reactive protein (CRP), platelets, albumin] measured at the same time as well as clinical disease activity and quality of life were assessed. RESULTS Among a total of 86 IBD patients under maintenance treatment with IFX, 64 [49 Crohn's disease, 15 ulcerative colitis (UC), 42 men, mean age 44.2±15.2 years, 41 in combination therapy with immunomodulator, six in intensified dose], with two available measurements of IFX-TLs and ATIs (A and B), were included in the study. The median levels of IF-TLs were 5.07 (interquartiles range: 1.60-12.73) μg/ml in measurement A and 4.68 (1.19-7.83) μg/ml in measurement B (P<0.0001). Patients whose dose was intensified after the first measurement showed an increase in their median IFX-TLs from 1.47 to 8.5 μg/ml, whereas patients with stable IFX dose showed a significant reduction in the median IFX-TLs from 5.65 to 3.8 μg/ml (P<0.0001). In the logistic regression analysis, the decrease in IFX-TL was correlated significantly and independently with the increase in CRP [odds ratio 5.2 (1.4-19.0), P=0.01]. CONCLUSION IBD patients on maintenance treatment with IFX show decreasing patterns of IFX-TLs over time associated with increasing patterns of CRP levels.
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26
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Kang B, Choi SY, Choi YO, Lee SY, Baek SY, Sohn I, Choe BH, Lee HJ, Choe YH. Infliximab Trough Levels Are Associated With Mucosal Healing During Maintenance Treatment With Infliximab in Paediatric Crohn's Disease. J Crohns Colitis 2019; 13:189-197. [PMID: 30452616 DOI: 10.1093/ecco-jcc/jjy155] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [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] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS Mucosal healing is an important treatment goal in Crohn's disease. We investigated the association between serum infliximab trough levels and mucosal healing, and the infliximab cut-off levels required for mucosal healing in paediatric patients. METHODS In this multicentre, retrospective, cross-sectional study, medical records and electronic data of paediatric patients with luminal Crohn's disease, who had received infliximab for ≥1 year, were examined. Ileocolonoscopy was performed on the same day as the infliximab infusion, and serum samples for trough levels were collected immediately before infusion. Mucosal healing was defined as a Simple Endoscopic Score for Crohn's Disease of 0. Univariate, multivariate logistic regression, and receiver operating characteristic curve analyses were performed. RESULTS Overall, 105 patients [median age 14.8 years] were included, with mucosal healing observed in 48.6%. Median serum infliximab trough levels were higher in patients with mucosal healing [4.5 µg/mL] than without [3.3 µg/mL, p = 0.002]. In the final multivariate model, infliximab trough level ≥4.2 µg/mL [p = 0.002] and ≥1-year duration from diagnosis to infliximab treatment [p = 0.003] were positively and negatively associated with mucosal healing, respectively. The infliximab trough level for achieving mucosal healing with a specificity of 80% was ≥5 µg/mL. CONCLUSIONS Associations between serum infliximab trough concentrations and mucosal healing were observed in paediatric patients. Identification of the infliximab trough level that positively associates with mucosal healing in most paediatric patients with Crohn's disease [≥5 µg/mL] may guide treatment decisions to optimise therapeutic response in the era of treat-to-target.
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Affiliation(s)
- Ben Kang
- Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu, South Korea.,Crohn's and Colitis Association in Daegu-Gyeongbuk [CCAiD], Daegu, South Korea
| | - So Yoon Choi
- Department of Pediatrics, Inje University College of Medicine, Busan, South Korea
| | - Young Ok Choi
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Soo-Youn Lee
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sun-Young Baek
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Insuk Sohn
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Byung-Ho Choe
- Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu, South Korea.,Crohn's and Colitis Association in Daegu-Gyeongbuk [CCAiD], Daegu, South Korea
| | - Hae Jeong Lee
- Department of Pediatrics, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
| | - Yon Ho Choe
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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27
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Michopoulos S, Paspatis G, Triantafyllou K, Potamianos S, Nikolopoulou V, Akriviadis E, Karagiannis JA, Ladas S, Tampaki M, Tzathas C. A multicenter, prospective, observational study of the long-term outcomes of Crohn's disease patients under routine care management in Greece. Ann Gastroenterol 2018; 31:583-592. [PMID: 30174395 PMCID: PMC6102459 DOI: 10.20524/aog.2018.0295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 06/12/2018] [Indexed: 11/11/2022] Open
Abstract
Background Real-world data on management patterns and long-term outcomes of patients with inadequately controlled Crohn’s disease (CD) in Greece are scarce. Methods This was a multicenter, prospective observational study of 18–65-year-old CD patients whose physicians judged that their current therapy was inadequate to control their condition and therefore decided to switch treatment. Data were collected at enrollment (time of switch), and 30, 54 and 104 weeks post-enrollment. Results Sixty-six eligible patients (median age: 35.8 years; 56.1% males; median CD diagnosis duration: 2.3 years) were enrolled by nine hospital sites. At the time of treatment switch, 66.7% had “mild” (CD activity index [CDAI] <220) and 30.3% “moderate-to-severe” (220≤CDAI≤450) disease activity. Ileocolonic involvement, extraintestinal manifestations, prior CD-related surgeries and prior corticosteroid use were reported in 65.2%, 51.5%, 24.2% and 78.8% of patients, respectively. Throughout the study, most patients were managed with anti-tumor necrosis factor (TNF) medications (74.2%/74.1% infliximab; 10.6%/13.8% adalimumab at enrollment/end of study, respectively). At 54 and 104 weeks post-enrollment, the baseline CDAI score (median 174.5) decreased to 145.5 and 146.0 points (P<0.001) and the baseline C-reactive protein level (median: 13.6 mg/L) decreased to 3.5 and 3.0 mg/L (P<0.001), respectively, not differing statistically between patients with “mild” and “moderate-to-severe” disease activity. In this patient population, 56.1% were corticosteroid-free throughout observation, while for the remaining 43.9%, the mean percentage corticosteroid-free period was 80.2%. CD-related surgeries and hospitalizations were reported in 8.1% and 19.4%, respectively. Conclusion Under routine care in Greece, inadequately controlled CD patients were mainly switched to anti-TNFs, which lowered disease activity and reduced corticosteroid use.
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Affiliation(s)
- Spyridon Michopoulos
- Gastroenterology Department, "Alexandra" General Hospital of Athens (Spyridon Michopoulos), Greece
| | - Gregorios Paspatis
- Gastroenterology Department, "Venizeleio Pananeio" General Hospital of Heraklion, Crete (Gregorios Paspatis), Greece
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine - Propaedeutic, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens (Konstantinos Triantafyllou), Greece
| | - Spyridon Potamianos
- Gastroenterology Department, University General Hospital of Larissa (Spyridon Potamianos), Greece
| | - Vassiliki Nikolopoulou
- Gastroenterology Department, University General Hospital of Patras, Rio (Vassiliki Nikolopoulou), Greece
| | - Evangelos Akriviadis
- 3 Internal Medicine Department, "Diavalkaniko" Medical Center of Thessaloniki, Thessaloniki (Evangelos Akriviadis), Greece
| | - John A Karagiannis
- Gastroenterology Department, "Konstantopouleio-Agia Olga" General Hospital of Nea Ionia, Athens (John A. Karagiannis†), Greece
| | - Spyridon Ladas
- First Propaedeutic Clinic of Internal Medicine, "Laiko" General Hospital of Athens (Spyridon Ladas), Greece
| | - Maria Tampaki
- Merck Sharp & Dohme Pharmaceutical, Industrial and Commercial S.A., Athens (Maria Tampaki), Greece
| | - Charalambos Tzathas
- Gastroenterology Department, "Tzaneio" General Hospital of Piraeus, Piraeus (Charalambos Tzathas), Greece
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28
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Schulze H, Esters P, Hartmann F, Stein J, Christ C, Zorn M, Dignass A. A prospective cohort study to assess the relevance of vedolizumab drug level monitoring in IBD patients. Scand J Gastroenterol 2018; 53:670-676. [PMID: 29560811 DOI: 10.1080/00365521.2018.1452974] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [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: 02/07/2023]
Abstract
BACKGROUND Vedolizumab (VDZ) drug monitoring strategies in inflammatory bowel disease (IBD) patients have not been systematically investigated so far. We evaluated the correlation between VDZ trough levels (VTL) and the treatment response in IBD. METHODS Fifty-one patients with active IBD on or starting a therapy with VDZ were enrolled in this prospective and observational single centre study. Disease activity indices, blood tests, and anthropometric parameters were assessed over a time period of 6 months. One hundred and fifty-five VDZ serum trough levels were measured directly before the next scheduled application using liquid chromatography mass spectrometry (LC-MS/MS). RESULTS VDZ treatment was found to be clinically effective (Harvey Bradshaw Index (HBI) dropping from 10 to 5.5 points (p < .0005) in Crohn's disease (CD) patients; partial Mayo score (pMS) from 4.4 to 2.1 points (p < .0005) in ulcerative colitis patients (UC). CRP levels tended to decrease and haemoglobin levels to increase under VDZ therapy. CD patients with a serum CRP level lower than 5 mg/l exhibited significantly higher VTL than those with elevated CRP levels (34.9 versus 21.7 µg/ml, p = .00153). UC patients with haemoglobin levels higher 12 g/dl at the time of VTL measurement had significantly higher VTL compared to patients with lower haemoglobin levels (35.4 versus 15.6 µg/ml, p < .0005). CONCLUSIONS Our data suggest a significant correlation between VTL and response to therapy in IBD patients (higher VTL associated with better response).
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Affiliation(s)
- Hermann Schulze
- a Department of Medicine I , Agaplesion Markus Hospital , Frankfurt , Germany
| | - Philip Esters
- a Department of Medicine I , Agaplesion Markus Hospital , Frankfurt , Germany
| | - Franz Hartmann
- a Department of Medicine I , Agaplesion Markus Hospital , Frankfurt , Germany
| | - Juergen Stein
- b Interdisziplinäres Crohn Colitis Centrum , Frankfurt , Germany
| | | | | | - Axel Dignass
- a Department of Medicine I , Agaplesion Markus Hospital , Frankfurt , Germany
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29
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Gorovits B, Baltrukonis DJ, Bhattacharya I, Birchler MA, Finco D, Sikkema D, Vincent MS, Lula S, Marshall L, Hickling TP. Immunoassay methods used in clinical studies for the detection of anti-drug antibodies to adalimumab and infliximab. Clin Exp Immunol 2018; 192:348-365. [PMID: 29431871 PMCID: PMC5980437 DOI: 10.1111/cei.13112] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [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] [Subscribe] [Scholar Register] [Accepted: 02/01/2018] [Indexed: 12/13/2022] Open
Abstract
We examined the assay formats used to detect anti-drug antibodies (ADA) in clinical studies of the anti-tumour necrosis factor (TNF) monoclonal antibodies adalimumab and infliximab in chronic inflammatory disease and their potential impact on pharmacokinetic and clinical outcomes. Using findings of a recent systematic literature review of the immunogenicity of 11 biological/biosimilar agents, we conducted an ancillary qualitative review of a subset of randomized controlled trials and observational studies of the monoclonal antibodies against anti-TNF factor adalimumab and infliximab. Among studies of adalimumab and infliximab, the immunoassay method used to detect antibodies was reported in 91 of 111 (82%) and 154 of 206 (75%) adalimumab and infliximab studies, respectively. In most adalimumab and infliximab studies, an enzyme-linked immunosorbent assay or radioimmunoassay was used [85 of 91 (93%) and 134 of 154 (87%), respectively]. ADA incidence varied widely among assays and inflammatory diseases (adalimumab, 0-87%; infliximab, 0-79%). Pharmacokinetic and clinical outcomes were only reported for ADA-positive patients in 38 of 91 (42%) and 61 of 154 (40%) adalimumab and infliximab studies, respectively. Regardless of assay format or biological used, ADA formation was associated with lower serum concentrations, reduced efficacy and elevated rates of infusion-related reactions. Consistent with previous recommendations to improve interpretation of immunogenicity data for biologicals, greater consistency in reporting of assay methods and clinical consequences of ADA formation may prove useful. Additional standardization in immunogenicity testing and reporting, application of modern, robust assays that satisfy current regulatory expectations and implementation of international standards for marketed products may help to improve our understanding of the impact of immunogenicity to biologics.
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Affiliation(s)
| | | | | | | | | | | | | | - S. Lula
- Envision Pharma GroupLondonUK
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Feagan BG, Schwartz D, Danese S, Rubin DT, Lissoos TW, Xu J, Lasch K. Efficacy of Vedolizumab in Fistulising Crohn's Disease: Exploratory Analyses of Data from GEMINI 2. J Crohns Colitis 2018; 12:621-626. [PMID: 29471381 PMCID: PMC6018899 DOI: 10.1093/ecco-jcc/jjy019] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [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] [Received: 08/31/2017] [Accepted: 02/14/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS Medical management of fistulising Crohn's disease [CD] is constrained by the limited number of available therapies. We evaluated the efficacy of vedolizumab, a gut-selective α4β7 integrin antagonist approved for treating moderately to severely active CD, in a subpopulation of patients with fistulising CD who participated in the GEMINI 2 trial [NCT00783692]. METHODS Exploratory analyses of data from the GEMINI 2 trial were conducted in 461 responders to 6-week vedolizumab induction therapy who received maintenance placebo [VDZ/PBO, N = 153] or vedolizumab [VDZ/VDZ, N = 308]. Fistula closure rates were assessed at Weeks 14 and 52, and the time to fistula closure was analysed by the Cox proportional hazards model with adjustments for significant covariates. RESULTS At entry into the maintenance period, 153 [33%] patients had a history of fistulising disease and 57 [12%] patients had ≥1 active draining fistula. By Week 14, 28% of VDZ/VDZ-treated patients compared with 11% of VDZ/PBO-treated patients (95% confidence interval [CI], -11.4 to 43.9) achieved fistula closure. Corresponding rates at Week 52 were 31% and 11% (absolute risk reduction [ARR]: 19.7%; 95% CI, -8.9 to 46.2). Similarly, VDZ/VDZ-treated patients had faster time to fistula closure and were more likely to have fistula closure at Week 52 [33% vs 11%; HR: 2.54; 95% CI, 0.54-11.96]. Prior failure of antibiotic therapy was a negative predictor of fistula closure [HR: 0.217; 95% CI, 0.059-0.795; p = 0.021], whereas trough vedolizumab concentrations did not affect closure rates. CONCLUSIONS Our findings are consistent with the beneficial effect of vedolizumab treatment for fistulising CD.
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Affiliation(s)
- Brian G Feagan
- Robarts Clinical Trials, Robarts Research Institute, Western University, London, ON, Canada,Corresponding author: Brian G. Feagan, Robarts Clinical Trials, Robarts Research Institute, Western University, 100 Perth Dr., London, ON N6A 5K8, Canada. Tel: +1-519-931-5289 or 858-5087; Fax: +1-519-931-5278; E-mail:
| | - David Schwartz
- Inflammatory Bowel Disease Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Silvio Danese
- IBD Center, Humanitas Clinical and Research Center, Humanitas University, Rozzano, Milan, Italy
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | | | - Jing Xu
- Takeda Pharmaceuticals International Co., Cambridge, MA, USA
| | - Karen Lasch
- Takeda Pharmaceuticals USA, Inc., Deerfield, IL, USA
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31
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Freeman K, Connock M, Auguste P, Taylor-Phillips S, Mistry H, Shyangdan D, Court R, Arasaradnam R, Sutcliffe P, Clarke A. Clinical effectiveness and cost-effectiveness of use of therapeutic monitoring of tumour necrosis factor alpha (TNF-α) inhibitors [LISA-TRACKER® enzyme-linked immunosorbent assay (ELISA) kits, TNF-α-Blocker ELISA kits and Promonitor® ELISA kits] versus standard care in patients with Crohn's disease: systematic reviews and economic modelling. Health Technol Assess 2018; 20:1-288. [PMID: 27845027 DOI: 10.3310/hta20830] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Systematic reviews and economic modelling of clinical effectiveness and cost-effectiveness of therapeutic monitoring of tumour necrosis factor alpha (TNF-α) inhibitors [using LISA-TRACKER® enzyme-linked immunosorbent assay (ELISA) kits (Theradiag, Marne La Vallee, France, or Alpha Laboratories, Heriot, UK), TNF-α-Blocker ELISA kits (Immundiagnostik AG, Bensheim, Germany) and Promonitor® ELISA kits (Proteomika, Progenika Biopharma, Bizkaia, Spain)] versus standard care for Crohn's disease (CD). METHODS Multiple electronic databases were searched from inception to December 2014 in order to identify primary studies and meta-analyses. POPULATION Patients with moderate to severe active CD treated with infliximab (IFX) (Remicade®, Merck Sharp & Dohme Ltd, Kenilworth, NJ, USA) or adalimumab (ADA) (Humira®, AbbVie Inc., North Chicago, IL, USA). INTERVENTION Monitoring of serum anti-TNF-α (IFX or ADA) and/or of anti-drug antibody levels using test assays with a test-treatment algorithm. COMPARATOR Standard care. OUTCOMES Any patient-related outcome, test agreement and cost-effectiveness estimates. The quality assessments used recognised checklists (Quality Assessment of Diagnostic Accuracy Studies-2, Cochrane, Philips and Consolidated Health Economic Evaluation Reporting Standards). Evidence was synthesised using narrative review and meta-analysis. A Markov model was built in TreeAge Pro 2013 (TreeAge Software, Inc., Williamstown, MA, USA). The model had a 4-week cycle and a 10-year time horizon, adopted a NHS and Personal Social Services perspective and used a linked evidence approach. Costs were adjusted to 2013/14 prices and discounted at 3.5%. RESULTS We included 68 out of 2434 and 4 out of 2466 studies for the clinical effectiveness and cost-effectiveness reviews, respectively. Twenty-three studies comparing test methods were identified. Evidence on test concordance was sparse and contradictory, offering scant data for a linked evidence approach. Three studies [two randomised controlled trials (RCTs) and one retrospective observational study] investigated outcomes following implementation of a test algorithm. None used the specified commercial ELISA immunoassay test kits. Neither of the two RCTs demonstrated clinical benefit of a test-treatment regimen. A meta-analysis of 31 studies to estimate test accuracy for predicting clinical status indicated that 20-30% of test results are likely to be inaccurate. The four cost-effectiveness studies suggested that testing results in small cost reductions. In the economic analysis the base-case analysis showed that standard practice (no testing/therapeutic monitoring with the intervention tests) was more costly and more effective than testing for IFX. Sensitivity and scenario analyses gave similar results. The probabilistic sensitivity analysis indicated a 92% likelihood that the 'no-testing' strategy was cost-effective at a willingness to pay of £20,000 per quality-adjusted life-year. STRENGTHS AND LIMITATIONS Rigorous systematic reviews were undertaken; however, the underlying evidence base was poor or lacking. There was uncertainty about a linked evidence approach and a lack of gold standard for assay comparison. The only comparative evidence available for economic evaluation was for assays other than the intervention assays. CONCLUSIONS Our finding that testing is not cost-effective for IFX should be viewed cautiously in view of the limited evidence. Clinicians should be mindful of variation in performance of different assays and of the absence of standardised approaches to patient assessment and treatment algorithms. FUTURE WORK RECOMMENDATIONS There is substantial variation in the underlying treatment pathways and uncertainty in the relative effectiveness of assay- and test-based treatment algorithms, which requires further investigation. There is very little research evidence on ADA or on drug monitoring in children with CD, and conclusions on cost-effectiveness could not be reached for these. STUDY REGISTRATION This study is registered as PROSPERO CRD42014015278. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Karoline Freeman
- Warwick Evidence, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Martin Connock
- Warwick Evidence, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Peter Auguste
- Warwick Evidence, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Sian Taylor-Phillips
- Warwick Evidence, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Hema Mistry
- Warwick Evidence, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Deepson Shyangdan
- Warwick Evidence, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Rachel Court
- Warwick Evidence, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Ramesh Arasaradnam
- Clinical Sciences Research Institute, University of Warwick, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Paul Sutcliffe
- Warwick Evidence, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Aileen Clarke
- Warwick Evidence, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
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Vermeire S, Gils A, Accossato P, Lula S, Marren A. Immunogenicity of biologics in inflammatory bowel disease. Therap Adv Gastroenterol 2018; 11:1756283X17750355. [PMID: 29383030 PMCID: PMC5784568 DOI: 10.1177/1756283x17750355] [Citation(s) in RCA: 142] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 11/21/2017] [Indexed: 02/04/2023] Open
Abstract
Crohn's disease and ulcerative colitis are chronic inflammatory disorders of the gastrointestinal tract. Treatment options include biologic therapies; however, a proportion of patients lose response to biologics, partly due to the formation of anti-drug antibodies (ADAbs). Concomitant immunosuppressive agents reduce the development of ADAbs. This review article aims to assess the immunogenicity of biologic therapies and their clinical implications. A comprehensive literature search was conducted for articles published January 2009 to August 2015 reporting immunogenicity to adalimumab (ADM), certolizumab pegol (CZP), golimumab, infliximab (IFX), ustekinumab, and vedolizumab in inflammatory bowel disease (IBD). Eligible articles were reviewed and quality assessed by independent reviewers. Overall, 122 publications reporting 114 studies were assessed. ADAbs were reported for all agents, but the percentage of patients developing ADAbs was extremely variable, with the highest (65.3%) being for IFX administration to patients with IBD. ADAb presence was frequently associated with a reduction in primary efficacy and a loss of response, and, for IFX, an increase in adverse events (AEs). Lower serum levels of ADM, CZP and IFX were seen in ADAbs-positive rather than ADAbs-negative patients; pharmacokinetic data were unavailable for other therapies. Little information was available regarding the timing of ADAb development; studies reported their detection from as early as 10-14 days up to months after treatment initiation. Biologic therapies carry an intrinsic risk of immunogenicity, although reported rates of ADAbs vary considerably. The clinical implications of immunogenicity are a concern for effective treatment; further research, particularly into the more recently approved biologics, is required.
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Affiliation(s)
- Séverine Vermeire
- Department of Gastroenterology, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Ann Gils
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | | | - Sadiq Lula
- Market Access Solutions, Envision Pharma Group Ltd, London, UK
| | - Amy Marren
- Pfizer Innovative Health, Pfizer Inc, Collegeville, PA, USA
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Bar-Yoseph H, Levhar N, Selinger L, Manor U, Yavzori M, Picard O, Fudim E, Kopylov U, Eliakim R, Ben-Horin S, Chowers Y, Ungar B. Early drug and anti-infliximab antibody levels for prediction of primary nonresponse to infliximab therapy. Aliment Pharmacol Ther 2018; 47:212-218. [PMID: 29124774 DOI: 10.1111/apt.14410] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [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: 08/03/2017] [Revised: 08/18/2017] [Accepted: 10/16/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Primary nonresponse, defined as lack of clinical benefit during the induction phase, occurs in up to 30% of IBD patients treated with infliximab. The mechanisms underlying primary nonresponse have not yet been clearly defined. AIM To evaluate the association of early (week 2 and week 6) induction infliximab and anti-infliximab antibody levels with primary nonresponse. METHODS A retrospective observational case-control study of inflammatory bowel disease patients treated with infliximab and followed at Sheba Medical Center between 2009 and 2016 was performed. Pre-infusion infliximab and antibodies to infliximab (ATI) levels were measured by our previously described drug-tolerant ELISA assay. RESULTS Thirty-five primary nonresponders have been identified and matched with 105 primary responders (1:3 ratios). Both week 2 and week 6 infliximab levels were significantly lower among primary nonresponders compared to responders (week 2, 6: median level 7.2, 2.2 μg/mL vs 13.5, 9.5 μg/mL, P = .0019, P < .0001 respectively). Antibodies to infliximab appeared more frequently (either week 2 or 6, 68% vs 28% prevalence, P = .0004) and at higher levels in nonresponders compared to responders (week 2, 6: median ATI 7.3, 10.8 μg/mL-eq vs 3.8, 4.4 μg/mL-eq, P = .005, P = .008 respectively). Moreover, week 2 infliximab levels <6.8 μg/mL (AUC = 0.68, P = .002, sensitivity 50%, specificity 86%) and antibodies to infliximab levels >4.3 μg/mL-eq (AUC = 0.78, P = .0004, sensitivity 77%, specificity 71%) were predictive of primary nonresponse. Among the other clinical and demographic variables, higher baseline ulcerative colitis clinical score, infliximab monotherapy, prior adalimumab therapy and previous Crohn's disease-related surgeries were also associated with an increased risk of primary nonresponse. CONCLUSIONS Infliximab levels below 6.8 μg/mL and antibodies to infliximab levels above 4.3 μg/mL-eq before the second infusion are associated with primary nonresponse, especially among Crohn's disease patients.
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Affiliation(s)
- H Bar-Yoseph
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel.,Bruce Rappaport School of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - N Levhar
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - L Selinger
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - U Manor
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - M Yavzori
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - O Picard
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - E Fudim
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - U Kopylov
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - R Eliakim
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - S Ben-Horin
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Y Chowers
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel.,Bruce Rappaport School of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - B Ungar
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Cozijnsen MA, Samsom JN, de Ridder L. Anti-Tumour Necrosis Factor Therapy for Paediatric Crohn's Disease: Improved Benefits Through Treatment Optimisation, Deeper Understanding of Its Risks, and Reduced Costs due to Biosimilar Availability. Paediatr Drugs 2018; 20:19-28. [PMID: 29079905 DOI: 10.1007/s40272-017-0266-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Antibodies directed to tumour necrosis factor-α (TNF-α) are very effective in treating paediatric Crohn's disease (CD). Over the last few years, research has provided important new insights into how to optimise this treatment's effectiveness. Research on predictors for anti-TNF treatment responsiveness has revealed potential markers, but data on their accuracy in paediatric CD patients are lagging behind. Also, new evidence has become available on the safety profile of anti-TNF antibodies that suggests the assumed increased malignancy risk seen in patients on anti-TNF and thiopurine combination treatment may be linked more to thiopurine use and not to anti-TNF treatment. In addition, the early results of CT-P13, an infliximab biosimilar, in CD patients confirm the expected similarity with its originator. Thus, the effectiveness of anti-TNF antibody treatment is slowly improving, its malignancy risk is lower than assumed, and its costs are reduced by the introduction of equally effective biosimilars. Together, these trends allow for a more prominent role for anti-TNF antibodies in future treatment of paediatric CD.
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Mitrev N, Vande Casteele N, Seow CH, Andrews JM, Connor SJ, Moore GT, Barclay M, Begun J, Bryant R, Chan W, Corte C, Ghaly S, Lemberg DA, Kariyawasam V, Lewindon P, Martin J, Mountifield R, Radford-Smith G, Slobodian P, Sparrow M, Toong C, van Langenberg D, Ward MG, Leong RW. Review article: consensus statements on therapeutic drug monitoring of anti-tumour necrosis factor therapy in inflammatory bowel diseases. Aliment Pharmacol Ther 2017; 46:1037-1053. [PMID: 29027257 DOI: 10.1111/apt.14368] [Citation(s) in RCA: 135] [Impact Index Per Article: 19.3] [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: 07/09/2017] [Revised: 08/06/2017] [Accepted: 09/19/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) in inflammatory bowel disease (IBD) patients receiving anti-tumour necrosis factor (TNF) agents can help optimise outcomes. Consensus statements based on current evidence will help the development of treatment guidelines. AIM To develop evidence-based consensus statements for TDM-guided anti-TNF therapy in IBD. METHODS A committee of 25 Australian and international experts was assembled. The initial draft statements were produced following a systematic literature search. A modified Delphi technique was used with 3 iterations. Statements were modified according to anonymous voting and feedback at each iteration. Statements with 80% agreement without or with minor reservation were accepted. RESULTS 22/24 statements met criteria for consensus. For anti-TNF agents, TDM should be performed upon treatment failure, following successful induction, when contemplating a drug holiday and periodically in clinical remission only when results would change management. To achieve clinical remission in luminal IBD, infliximab and adalimumab trough concentrations in the range of 3-8 and 5-12 μg/mL, respectively, were deemed appropriate. The range may differ for different disease phenotypes or treatment endpoints-such as fistulising disease or to achieve mucosal healing. In treatment failure, TDM may identify mechanisms to guide subsequent decision-making. In stable clinical response, TDM-guided dosing may avoid future relapse. Data indicate drug-tolerant anti-drug antibody assays do not offer an advantage over drug-sensitive assays. Further data are required prior to recommending TDM for non-anti-TNF biological agents. CONCLUSION Consensus statements support the role of TDM in optimising anti-TNF agents to treat IBD, especially in situations of treatment failure.
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Frymoyer A, Hoekman DR, Piester TL, de Meij TG, Hummel TZ, Benninga MA, Kindermann A, Park KT. Application of Population Pharmacokinetic Modeling for Individualized Infliximab Dosing Strategies in Crohn Disease. J Pediatr Gastroenterol Nutr 2017; 65:639-45. [PMID: 28471911 DOI: 10.1097/MPG.0000000000001620] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES The pharmacokinetics of infliximab (IFX) is highly variable in children with Crohn disease (CD), and a one-size-fits-all approach to dosing is inadequate. Model-based drug dosing can help individualize dosing strategies. We evaluated the predictive performance and clinical utility of a published population pharmacokinetic model of IFX in children with CD. METHODS Within a cohort of 34 children with CD who had IFX trough concentrations measured, the pharmacokinetics of each patient was estimated in NONMEM using a published population pharmacokinetic model. Infliximab concentrations were then predicted based on each patient's dosing history and compared with actual measured concentrations (n = 59). In addition, doses 5 to 10 mg/kg and dosing intervals every 4 to 8 weeks were simulated in each patient to examine dose-trough relationships. RESULTS Predicted concentrations were within ±1.0 μg/mL of actual measured concentrations for 88% of measurements. The median prediction error (ie, measure of bias) was -0.15 μg/mL (95% confidence interval -0.37 to -0.05 μg/mL) and absolute prediction error (ie, measure of precision) was 0.26 μg/mL (95% confidence interval 0.15 to 0.40 μg/mL). At standard maintenance dosing of 5 mg/kg every 8 weeks, a trough >3 μg/mL was predicted to be achieved in 32% of patients. To achieve a trough >3 μg/mL, a dosing interval ≤every 6 weeks was predicted to be required in 29% of patients. CONCLUSIONS A published IFX population pharmacokinetic model demonstrated accurate predictive performance in a pediatric CD population. Individualized IFX dosing strategies in children with CD will be critical to consistently achieve trough concentrations associated with optimal outcomes.
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Roblin X, Boschetti G, Duru G, Williet N, Deltedesco E, Phelip JM, Peyrin-Biroulet L, Nancey S, Flourié B, Paul S. Distinct Thresholds of Infliximab Trough Level Are Associated with Different Therapeutic Outcomes in Patients with Inflammatory Bowel Disease: A Prospective Observational Study. Inflamm Bowel Dis 2017; 23:2048-53. [PMID: 28945636 DOI: 10.1097/MIB.0000000000001223] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Several studies have reported a strong correlation between infliximab (IFX) trough levels (trough levels of infliximab [TLI]) and clinical remission (CR). We aimed to determine threshold values of TLI associated with the occurrence of CR, with or without normal inflammatory biomarkers, including serum C-reactive protein (CRP) and fecal calprotectin (fCal). METHODS We included prospectively all consecutive patients with inflammatory bowel disease under IFX therapy (5 mg/kg every 8 wk) for at least 6 months. Disease activity (using the Crohn's Disease Activity Index or Mayo score) was recorded, and TLI, CRP, and fCal were measured before IFX infusion. RESULTS Two hundred thirteen patients (131 Crohn's disease) were included. The median TLIs were higher in patients who achieved CR compared with those in patients who did not (2.6 versus 1.2 μg/mL, P < 0.01). The median TLI were higher in patients achieving CR with CRP normalization or CR with fCal <250 μg/g in comparison with patients with persistent elevated CRP or fCal (3.5 versus 1.6 μg/mL, P < 0.01 and 4.9 versus 1.8 μg/mL, P < 0.001, respectively). Finally, the median TLIs were higher in patients achieving CR with normal CRP and fCal <50 μg/g in comparison with patients without strictly normal biomarkers (5.9 versus 2.1 μg/mL, P < 0.001). The more the expected level of response to IFX was stringent, the more the median TLI and optimal thresholds were high. CONCLUSIONS Threshold values of TLI differ according to therapeutic outcomes expected in patients with inflammatory bowel disease under maintenance therapy with IFX.
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Kampa KC, Morsoletto DBG, Loures MR, Pissaia A, Nones RB, Ivantes CAP. IMPORTANCE OF MEASURING LEVELS OF INFLIXIMAB IN PATIENTS TREATING INFLAMMATORY BOWEL DISEASE IN A BRAZILIAN COHORT. Arq Gastroenterol 2017; 54:333-337. [PMID: 28954041 DOI: 10.1590/s0004-2803.201700000-41] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 06/14/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Crohn's disease and ulcerative colitis are chronic inflammatory bowel diseases. In such pathologies, there is an increased production of alpha tumor necrosis factor (TNF-α). Patients, in whom the conventional immunosuppressant treatment fails, require the use of immunobiological therapy, such as anti-TNF-α, a monoclonal antibody. Infliximab is an anti-TNF-α drug, a chimerical immunoglobulin, with a murine component, which is responsible for the generation of immunogenicity against the drug and formation of anti-TNF-α antibodies. The presence of anti-drug antibodies may be responsible for adverse events and reduction of the drug's effectiveness. Patients with inflammatory bowel diseases undergoing therapy with biological medication, such as infliximab, can relapse overtime and this may not be translated into clinical symptoms. Thus, there is a need for a method to evaluate the efficacy of the drug, through the measurement of serum infliximab levels, as well as antibodies research. OBJECTIVE This study aimed to measure serum infliximab levels and anti-infliximab antibodies in patients with inflammatory bowel diseases post-induction phase and during maintenance therapy, and describe the therapeutic modifications that took place based on the serum levels results. METHODS It was a retrospective study, that included forty-five patients, with a total of 63 samples of infliximab measurement. RESULTS Twenty-one patients had an adequate infliximab serum level, 31 had subtherapeutic levels and 11 had supratherapeutic levels. Seven patients had their medication suspended due to therapeutic failure or high levels of antibodies to infliximab. CONCLUSION In conclusion, only a third of the patients had adequate infliximab levels and 36% presented with subtherapeutic levels at the end of the induction phase. Therapy optimization occurred based in about 46% of the samples results, demonstrating the importance of having this tool to help the clinical handling of patients with inflammatory bowel diseases ongoing biologic therapy.
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Affiliation(s)
- Katia Cristina Kampa
- Departamento de Gastroenterologia, Hepatologia e Transplante Hepático, Nossa Senhora das Graças Hospital, Curitiba, PR, Brasil
| | | | - Marcela Rocha Loures
- Departamento de Gastroenterologia, Hepatologia e Transplante Hepático, Nossa Senhora das Graças Hospital, Curitiba, PR, Brasil
| | - Alcindo Pissaia
- Departamento de Gastroenterologia, Hepatologia e Transplante Hepático, Nossa Senhora das Graças Hospital, Curitiba, PR, Brasil
| | - Rodrigo Bremer Nones
- Departamento de Gastroenterologia, Hepatologia e Transplante Hepático, Nossa Senhora das Graças Hospital, Curitiba, PR, Brasil
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Qiu Y, Mao R, Chen BL, Zhang SH, Guo J, He Y, Zeng ZR, Ben-Horin S, Chen MH. Effects of Combination Therapy With Immunomodulators on Trough Levels and Antibodies Against Tumor Necrosis Factor Antagonists in Patients With Inflammatory Bowel Disease: A Meta-analysis. Clin Gastroenterol Hepatol 2017; 15:1359-1372.e6. [PMID: 28232073 DOI: 10.1016/j.cgh.2017.02.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 02/06/2017] [Accepted: 02/08/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS It is not clear whether combination therapy with immunomodulators affects the immunogenicity of tumor necrosis factor (TNF) antagonists in patients with inflammatory bowel disease. We performed a meta-analysis to quantify the effects of combined immunomodulator therapy on the presence of antibodies against TNF antagonists (antidrug antibodies [ADAs]) and trough levels of anti-TNF agents. METHODS We systematically searched publication databases for studies that reported prevalence of ADAs in patients who received anti-TNF agents. Raw data from studies that met the inclusion criteria were pooled to determine effect estimates. We performed subgroup and metaregression analyses to determine the level of heterogeneity among study outcomes. RESULTS We analyzed findings from 35 studies that met inclusion criteria (results reported from 6790 patients with inflammatory bowel disease). The pooled risk ratio for formation of ADAs in patients receiving combined therapy with immunomodulators, versus that of patients receiving anti-TNF monotherapy, was 0.49 (95% confidence interval, 0.41-0.59; P < .001). However, the pooled analysis did not demonstrate a significant difference in trough levels of anti-TNF agents between patients with versus without concurrent use of immunomodulators (standardized mean difference, 0.11; 95% confidence interval, 0.19-0.41; P = .47). Subgroup analyses of patients treated with different TNF antagonists revealed no difference in the formation of ADAs (P = .50 for interaction); the protective effect of immunomodulators did not differ with type of drug patients were given (methotrexate vs thiopurines), or assay for ADA. We observed heterogeneity only among studies of patients with ulcerative colitis (I2 = 76%). Funnel plot and Egger test analyses indicated publication bias in the studies (P = .001). CONCLUSIONS In a meta-analysis of published studies, we associated combined treatment with immunomodulators with reduced risk of formation of antibodies against TNF antagonists in patients with inflammatory bowel disease.
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Affiliation(s)
- Yun Qiu
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Ren Mao
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Bai-Li Chen
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Sheng-Hong Zhang
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Jing Guo
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yao He
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Zhi-Rong Zeng
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Shomron Ben-Horin
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China; IBD Service, Department of Gastroenterology, Sheba Medical Center & Sackler School of Medicine, Tel-Aviv University, Tel Hashomer, Israel.
| | - Min-Hu Chen
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.
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Strand V, Balsa A, Al-Saleh J, Barile-Fabris L, Horiuchi T, Takeuchi T, Lula S, Hawes C, Kola B, Marshall L. Immunogenicity of Biologics in Chronic Inflammatory Diseases: A Systematic Review. BioDrugs 2017; 31:299-316. [PMID: 28612180 PMCID: PMC5548814 DOI: 10.1007/s40259-017-0231-8] [Citation(s) in RCA: 208] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES A systematic review was conducted to explore the immunogenicity of biologic agents across inflammatory diseases and its potential impact on efficacy/safety. METHODS Literature searches were conducted through November 2016 to identify controlled and observational studies of biologics/biosimilars administered for treatment of rheumatoid arthritis (RA), psoriatic arthritis (PsA), juvenile idiopathic arthritis (JIA), ankylosing spondylitis (AS), non-radiographic axial spondyloarthritis (nr-axSpA), psoriasis (Ps), Crohn's disease, and ulcerative colitis. RESULTS Of >21,000 screened publications, 443 were included. Anti-drug antibody (ADAb) rates varied widely among biologics across diseases (and are not directly comparable because of immunoassay heterogeneity); the highest overall rates were reported with infliximab (0-83%), adalimumab (0-54%), and infliximab biosimilar CT-P13 (21-52%), and the lowest with secukinumab (0-1%), ustekinumab (1-11%), etanercept (0-13%), and golimumab (0-19%). Most ADAbs were neutralizing, except those to abatacept and etanercept. ADAb+ versus ADAb- patients had lower rates of clinical response to adalimumab (RA, PsA, JIA, AS, Ps), golimumab (RA), infliximab (RA, PsA, AS, Ps), rituximab (RA), ustekinumab (Ps), and CT-P13 (RA, AS). Higher rates of infusion-related reactions were reported in infliximab- and CT-P13-treated ADAb+ patients. Background immunosuppressives/anti-proliferatives reduced biologic immunogenicity across diseases. CONCLUSIONS Based on reviewed reports, biologic/biosimilar immunogenicity differs among agents, with the highest rates observed with infliximab and adalimumab. As ADAb formation in biologic-/biosimilar-treated patients may increase the risk of lost response, the immunogenicity of these agents is an important (albeit not the only) consideration in the treatment decision-making process.
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Affiliation(s)
- Vibeke Strand
- Division of Immunology/Rheumatology, Stanford University School of Medicine, 306 Ramona Road, Portola Valley, CA, 94028, USA.
| | - Alejandro Balsa
- Rheumatology Unit, Instituto de Investigación Sanitaria del Hospital Universitario La Paz (IdiPAZ), Madrid, Spain
| | - Jamal Al-Saleh
- Rheumatology Section, Dubai Hospital, Dubai, United Arab Emirates
| | - Leonor Barile-Fabris
- Hospital de Especialidades Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, México City, Mexico
| | - Takahiko Horiuchi
- Department of Internal Medicine, Kyushu University Beppu Hospital, Beppu, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Sadiq Lula
- Market Access Solutions, Envision Pharma Group, London, UK
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Liefferinckx C, Minsart C, Toubeau JF, Cremer A, Amininejad L, Quertinmont E, Devière J, Gils A, van Gossum A, Franchimont D. Infliximab Trough Levels at Induction to Predict Treatment Failure During Maintenance. Inflamm Bowel Dis 2017; 23:1371-1381. [PMID: 28498153 DOI: 10.1097/mib.0000000000001120] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [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] [Indexed: 02/07/2023]
Abstract
BACKGROUND Infliximab (IFX) is indicated for the treatment of inflammatory bowel diseases (IBD). Nevertheless, loss of response (LOR) to IFX is reported in up to 10% to 30% of patients within the first year of treatment. Our objective was to evaluate the impact of the pharmacokinetics of IFX at induction on treatment failure. METHODS This is a longitudinal cohort study on 269 patients with IBD treated with IFX in a single center. A total of 2331 blood samples were prospectively collected from 2007 until March 2015 with a retrospective analysis of clinical data. IFX trough levels (TLs) were measured by enzyme-linked immunosorbent assay. Antibodies to IFX were measured by drug-sensitive bridging assay. RESULTS During follow-up, patients were defined according to treatment outcome. At week 6, median IFX TL in patients requiring a switch to another treatment due to LOR (LOR switched group) (2.32 μg/mL [0.12-19.93 μg/mL]) was lower than in patients with long-term response (long-term responders) (8.66 μg/mL [0.12-12.09 μg/mL], P = 0.007) and in patients responding to optimization (LOR optimized group) (7.28 μg/mL [0.17-14.91 μg/mL], P = 0.021). At week 2, median IFX TL was lower in the LOR switched group (5.7 μg/mL [0.15-12.09 μg/mL]) compared with the long-term responders (11.92 μg/mL [0.14-19.93 μg/mL], P = 0.041) but no significant difference was reached with the LOR optimized group (11.91 μg/mL [0.23-12.09 μg/mL], P = 0.065). In the LOR switched group, median IFX TL at induction (weeks 2 and 6) was significantly lower when patients had been previously exposed to anti-tumor necrosis factor compared with naive patients (0.91 μg/mL [0.12-4.4 μg/mL] versus 6.6 μg/mL [0.15-19.93 μg/mL], P = 0.044). CONCLUSIONS This study suggests that patients who do not respond to any optimization strategy have lower IFX TLs during induction at week 6. IFX TLs measured early on at induction might predict treatment failure to IFX during maintenance.
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Affiliation(s)
- Claire Liefferinckx
- *Laboratory of Experimental Gastroenterology, Université libre de Bruxelles, Brussels, Belgium; †Electrical Power Engineering Unit, Université de Mons, Mons, Belgium; ‡Department of Gastroenterology, Erasme Hospital, Brussels, Belgium; and §Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Belgium
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Freeman K, Taylor-Phillips S, Connock M, Court R, Tsertsvadze A, Shyangdan D, Auguste P, Mistry H, Arasaradnam R, Sutcliffe P, Clarke A. Test accuracy of drug and antibody assays for predicting response to antitumour necrosis factor treatment in Crohn's disease: a systematic review and meta-analysis. BMJ Open 2017; 7:e014581. [PMID: 28674134 PMCID: PMC5734585 DOI: 10.1136/bmjopen-2016-014581] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To present meta-analytic test accuracy estimates of levels of antitumour necrosis factor (anti-TNF) and antibodies to anti-TNF to predict loss of response or lack of regaining response in patients with anti-TNF managed Crohn's disease. METHODS MEDLINE, Embase, the Cochrane Library and Science Citation Index were searched from inception to October/November 2014 to identify studies which reported 2×2 table data of the association between levels of anti-TNF or its antibodies and clinical status. Hierarchical/bivariate meta-analysis was undertaken with the user-written 'metandi' package of Harbord and Whiting using Stata V.11 software, for infliximab, adalimumab,anti-infliximab and anti-adalimumab levels as predictors of loss of response. Prevalence of Crohn's disease in included studies was meta-analysed using a random effects model in MetaAnalyst software to calculate positive and negative predictive values. The search was updated in January 2017. RESULTS 31 studies were included in the review. Studies were heterogeneous with respect to the type of test used, criteria for establishing response and loss of response, population examined and results. Meta-analytic summary point estimates for sensitivity and specificity were 65.7% and 80.6% for infliximab trough levels and 56% and 79% for antibodies to infliximab, respectively. Pooled results for adalimumab trough levels and antibodies to adalimumab were similar. Pooled positive and negative predictive values ranged between 70% and 80% implying that between 20% and 30% of both positive and negative test results may be incorrect in predicting loss of response. CONCLUSION The available evidence suggests that these tests have modest predictive accuracy for clinical status; direct test accuracy comparisons in the same population are needed. More clinical trial evidence from test-treat studies is required before the clinical utility of the tests can be reliably evaluated.
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Affiliation(s)
- Karoline Freeman
- Warwick Medical School, University of Warwick, Coventry, Warwickshire, UK
| | | | - Martin Connock
- Warwick Medical School, University of Warwick, Coventry, Warwickshire, UK
| | - Rachel Court
- Warwick Medical School, University of Warwick, Coventry, Warwickshire, UK
| | | | - Deepson Shyangdan
- Warwick Medical School, University of Warwick, Coventry, Warwickshire, UK
| | - Peter Auguste
- Warwick Medical School, University of Warwick, Coventry, Warwickshire, UK
| | - Hema Mistry
- Warwick Medical School, University of Warwick, Coventry, Warwickshire, UK
| | - Ramesh Arasaradnam
- Warwick Medical School, University of Warwick, Coventry, Warwickshire, UK
- Department of Gastroenterology, University Hospital Coventry and Warwickshire, Coventry, UK
| | - Paul Sutcliffe
- Warwick Medical School, University of Warwick, Coventry, Warwickshire, UK
| | - Aileen Clarke
- Warwick Medical School, University of Warwick, Coventry, Warwickshire, UK
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Johnston EL, Warner BD, Digby-Bell JL, Unsworth N, Anderson S, Sanderson JD, Arkir Z, Irving PM. Utilisation of anti-TNF levels in a UK tertiary IBD centre. Frontline Gastroenterol 2017; 8:189-195. [PMID: 28839908 PMCID: PMC5558278 DOI: 10.1136/flgastro-2016-100739] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 07/27/2016] [Revised: 11/04/2016] [Accepted: 11/08/2016] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To ascertain how anti-tumour necrosis factor (TNF) drug and anti-drug antibody levels testing is used in a 'real-world' setting to optimise inflammatory bowel disease (IBD) treatment. DESIGN Retrospective cohort study of prospectively collected patient data. SETTING Tertiary IBD centre in London, UK. PATIENTS All patients at Guy's and St Thomas' Hospitals on anti-TNF who had levels measured between the start of testing in 2012 and October 2014. INTERVENTIONS Anti-TNF drug and anti-drug antibody levels as part of routine monitoring. MAIN OUTCOME MEASURES Indication for measuring levels and changes in management made as a result of the levels. RESULTS 330 infliximab levels were carried out in 199 patients and 143 adalimumab levels were carried out in 103 patients. Levels were primarily done in those with evidence of loss of response; 37% of infliximab levels and 52% of adalimumab levels. Levels resulted in a change in management in 26% of patients in infliximab group and 25% of patients in adalimumab group; however, this was greater in those with loss of response, 62% and 61% respectively. Anti-drug antibodies were detected in 7% of patients. CONCLUSIONS Our early experience has demonstrated that measuring anti-TNF drug and anti-drug antibody levels can be useful in the optimisation of IBD management. In an increasing number of patients, particularly those with evidence of loss of response, it allows early decisions to be made regarding changing therapy. It also offers the potential for significant cost-saving by preventing pointless dose escalation in the context of therapeutic levels or when high-level anti-drug antibodies are present.
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Affiliation(s)
- E L Johnston
- Department of Gastroenterology, Guy's and St Thomas’ Hospitals NHS Foundation Trust, London, UK
| | - B D Warner
- Department of Gastroenterology, Guy's and St Thomas’ Hospitals NHS Foundation Trust, London, UK
| | - J L Digby-Bell
- Department of Gastroenterology, Guy's and St Thomas’ Hospitals NHS Foundation Trust, London, UK
| | - N Unsworth
- Viapath Pathology Services, Guy's and St Thomas’ Hospitals NHS Foundation Trust, London, UK
| | - S Anderson
- Department of Gastroenterology, Guy's and St Thomas’ Hospitals NHS Foundation Trust, London, UK
| | - J D Sanderson
- Department of Gastroenterology, Guy's and St Thomas’ Hospitals NHS Foundation Trust, London, UK
| | - Z Arkir
- Viapath Pathology Services, Guy's and St Thomas’ Hospitals NHS Foundation Trust, London, UK
| | - P M Irving
- Department of Gastroenterology, Guy's and St Thomas’ Hospitals NHS Foundation Trust, London, UK
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Vande Casteele N, Khanna R. Therapeutic Drug Monitoring of Golimumab in the Treatment of Ulcerative Colitis. Pharm Res 2017; 34:1556-1563. [PMID: 28374338 DOI: 10.1007/s11095-017-2150-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 03/21/2017] [Indexed: 02/08/2023]
Abstract
Ulcerative colitis (UC) is a relapsing-remitting chronic inflammatory disorder affecting the mucosal surface in a continuous manner from the rectum through part of, or the entire, colon. Patients with severe disease and those who become refractory or intolerant to corticosteroids and/or immunosuppressants, require treatment with biologic agents that target tumor necrosis factor-α (TNF). Golimumab, a fully human monoclonal antibody, is the latest TNF antagonist to get approved for the treatment of moderate-to-severe UC. Subcutaneously administered golimumab induces and maintains clinical response, remission, and mucosal healing. Serum concentrations of golimumab are associated with response to therapy, as patients with higher drug exposure are more likely to achieve these outcomes. Since various patient and disease-related factors were shown to influence the pharmacokinetics of TNF antagonists, drug exposure may be variable over time and between patients, affecting success of therapy. A major contributing factor is immunogenicity, with development of anti-drug antibodies (ADAb) and an accelerated clearance of drug as a result. Although there is a growing body of evidence to support therapeutic drug monitoring (TDM) for infliximab and adalimumab, two other TNF antagonists, only limited data is available for golimumab. In addition, the clinically important drug exposure thresholds are not widely known, which has limited the use of TDM for golimumab in clinical practice. This review summarizes available data regarding the use of golimumab for UC, with emphasis on the pharmacokinetics, exposure-response relationship, and the role of TDM in optimizing therapy.
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Affiliation(s)
- Niels Vande Casteele
- Department of Medicine, University of California San Diego, 9500 Gilman Drive #0956, La Jolla, California, 92093, USA. .,Robarts Clinical Trials Inc., Robarts Research Institute, London, Ontario, Canada.
| | - Reena Khanna
- Robarts Clinical Trials Inc., Robarts Research Institute, London, Ontario, Canada.,Department of Medicine, University of Western Ontario, London, Ontario, Canada
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Strik AS, van den Brink GR, Ponsioen C, Mathot R, Löwenberg M, D'Haens GR. Suppression of anti-drug antibodies to infliximab or adalimumab with the addition of an immunomodulator in patients with inflammatory bowel disease. Aliment Pharmacol Ther 2017; 45:1128-1134. [PMID: 28230306 DOI: 10.1111/apt.13994] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [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: 10/11/2016] [Revised: 11/15/2016] [Accepted: 01/26/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Loss of response to anti-tumour necrosis factor (TNF) therapy in patients with inflammatory bowel disease (IBD) is often caused by anti-drug antibody formation with neutralisation of drug effect. Addition of an immunomodulator has been suggested to reduce immunogenicity, leading to regained response. AIM To investigate whether addition of an immunomodulator to anti-TNF monotherapy could lead to anti-drug antibody suppression and regained clinical response in IBD patients. METHODS We retrospectively collected measurements of infliximab or adalimumab serum concentrations and anti-drug antibodies to identify anti-drug positive patients with loss response who were given an immunomodulator. RESULTS Anti-drug antibodies against infliximab and adalimumab were detected in 98/376 (26%) and in 61/226 (27%) patients, respectively. Immunomodulators were given to 17/159 patients. Clinical response was recaptured in 6/10 patients receiving a thiopurine and in all (7/7) patients receiving methotrexate. In 7/8 patients on infliximab, serum concentrations increased (median 2.84 μg/mL; IQR: 1.19-4.98) and in 6/9 patients on adalimumab (median 3.10 μg/mL; IQR: 1.45-4.45). This was accompanied by a decrease in anti-drug antibodies to undetectable levels (median 11 months for both anti-TNF agents). In 23 patients, no immunomodulator was added but anti-TNF interval was shortened (17/23) or dosage was increased (6/23), which resulted in a clinical response in 10/17 and 2/6 patients, respectively. CONCLUSION In 77% of IBD patients with loss of response due to immunogenicity, addition of immunomodulator resulted in undetectable anti-drug antibody levels, increased serum drug concentrations and regained clinical response. This strategy should be considered in this patient population before switching to other agents.
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Affiliation(s)
- A S Strik
- Department of Gastroenterology, Academic Medical Centre Amsterdam, Amsterdam, the Netherlands
| | - G R van den Brink
- Department of Gastroenterology, Academic Medical Centre Amsterdam, Amsterdam, the Netherlands
| | - C Ponsioen
- Department of Gastroenterology, Academic Medical Centre Amsterdam, Amsterdam, the Netherlands
| | - R Mathot
- Department Hospital Pharmacy, Academic Medical Centre Amsterdam, Amsterdam, the Netherlands
| | - M Löwenberg
- Department of Gastroenterology, Academic Medical Centre Amsterdam, Amsterdam, the Netherlands
| | - G R D'Haens
- Department of Gastroenterology, Academic Medical Centre Amsterdam, Amsterdam, the Netherlands
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Bor R, Farkas K, Fábián A, Bálint A, Milassin Á, Rutka M, Matuz M, Nagy F, Szepes Z, Molnár T. Clinical role, optimal timing and frequency of serum infliximab and anti-infliximab antibody level measurements in patients with inflammatory bowel disease. PLoS One 2017; 12:e0172916. [PMID: 28362851 DOI: 10.1371/journal.pone.0172916] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 02/06/2017] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Serum infliximab (IFX) and antibody-to-infliximab (ATI) levels are objective parameters, that may have a great role in the therapeutic decisions during maintenance biological therapy. RESEARCH DESIGN AND METHODS 48 inflammatory bowel disease patients receiving maintenance IFX therapy were prospectively enrolled and divided into adequate (complete remission N = 20) and inadequate responder (partial response, loss of response, dose escalation; N = 28) groups. Blood samples were collected just before (trough level, TL) and two (W2aTL) and six weeks (W6aTL) after the administration of IFX. RESULTS Single measurement of ATI titer was insufficient for predicting therapeutic response due to transient expression of ATI, however, using the three points' measurements, significant difference has been detected between the adequate and inadequate responder group (5.0% vs 35.7%; p = 0.016). The mean value of TL was significantly higher in the adequate responder group (3.11±1.64 vs.1.19±1.11; p<0.001) without further difference on the second and sixth week. Sensitivity and specificity for predicting the therapeutic response were 85.0% and 71.4% based on the cut-off value of TL 2.0 μg/ml. CONCLUSION Simultaneous measurement of serum IFX level prior to administration of regular IFX infusion and ATI titers significantly increase the diagnostic accuracy for the therapeutic decision in patients uncertainly responding to the therapy. The measurement of W2aTL and W6aTL levels did not result in further improvement in the prediction of therapeutic response.
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Abstract
INTRODUCTION Anti-TNFα therapy has revolutionised treatment of inflammatory bowel disease, however primary non-response and secondary loss of response are a significant problem. Therapeutic drug monitoring (TDM) has recently emerged as a means of optimising use of anti-TNFα agents. Areas covered: TDM of anti-TNFα agents can guide clinical decisions during treatment failure events, prevent treatment failure events, and potentially result in significant healthcare cost saving. TDM for anti-TNFα agent involves measurement of drug levels and anti-drug antibodies, and can be performed reactively or proactively. Reactive TDM reserves testing for treatment failure events, while proactive TDM also consists of periodic TDM for patients responding to anti-TNFα therapy to allow treatment optimisation. Generation of anti-drug antibodies is recognised as one important mechanism of treatment failure and adverse events. Expert opinion: Evidence strongly supports TDM at time of treatment failure, while studies employing proactive TDM have demonstrated conflicting results. TDM can also help better select patients likely to remain in clinical remission on anti-TNFα treatment interruption. Currently TDM is used to optimise anti-TNFα treatment, but it is not used by most clinicians to prevent adverse reactions to anti-TNFα agents.
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Affiliation(s)
- Nikola Mitrev
- a Concord Hospital IBD Service, Department of Gastroenterology , Concord Repatriation General Hospital , Sydney , Australia
| | - Rupert W Leong
- a Concord Hospital IBD Service, Department of Gastroenterology , Concord Repatriation General Hospital , Sydney , Australia
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Smits LJT, Derikx LAAP, de Jong DJ, Boshuizen RS, van Esch AAJ, Drenth JPH, Hoentjen F. Clinical Outcomes Following a Switch from Remicade® to the Biosimilar CT-P13 in Inflammatory Bowel Disease Patients: A Prospective Observational Cohort Study. J Crohns Colitis 2016; 10:1287-1293. [PMID: 27095751 DOI: 10.1093/ecco-jcc/jjw087] [Citation(s) in RCA: 111] [Impact Index Per Article: 13.9] [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: 12/18/2015] [Accepted: 04/07/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIMS The biosimilar of Remicade®, CT-P13, recently entered the European market. Clinical data on switching from Remicade® to CT-P13 in inflammatory bowel disease [IBD] are scarce. We aimed to prospectively investigate efficacy, safety, pharmacokinetic profile, and immunogenicity following a switch from Remicade® to CT-P13 in IBD patients. METHODS Remicade®-treated IBD patients at the Radboud university medical centre who switched to CT-P13 were included in this prospective observational cohort study. Primary endpoint was change in Harvey-Bradshaw Index for Crohn's disease [CD] and Simple Clinical Colitis Activity Index for ulcerative colitis [UC] at week 16. We measured C-reactive protein [CRP], faecal calprotectin [FCP], infliximab trough level [TL] and anti-drug antibodies [ADAs] and documented adverse events. RESULTS Our cohort consisted of 83 patients (28 males, 57 CD, 24 UC, 2 IBD-unclassified [IBD-U]). The median age was 36 years, range 18-79. Median change in disease activity was 0 [range -23 to +7] for CD and 0 [range -3 to +6] for UC/IBD-U. Median CRP and FCP levels did not change significantly during follow-up. Median TL increased from 3.5 µg/ml [range 0-18] to 4.2 µg/ml [range 0-21] at week 16 [p = 0.010]. Two patients developed a new detectable ADA response during follow-up and five patients discontinued CT-P13. No serious adverse events occurred. CONCLUSIONS We demonstrated that switching from Remicade® to CT-P13 in a real-life cohort of IBD patients did not have a significant impact on short-term clinical outcomes. These results suggest that switching from Remicade® to CT-P13 for the treatment of IBD is feasible.
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Affiliation(s)
- Lisa J T Smits
- Inflammatory Bowel Disease Centre, Department of Gastroenterology and Hepatology, Radboud university medical centre, Nijmegen, The Netherlands
| | - Lauranne A A P Derikx
- Inflammatory Bowel Disease Centre, Department of Gastroenterology and Hepatology, Radboud university medical centre, Nijmegen, The Netherlands
| | - Dirk J de Jong
- Inflammatory Bowel Disease Centre, Department of Gastroenterology and Hepatology, Radboud university medical centre, Nijmegen, The Netherlands
| | - Ronald S Boshuizen
- Sanquin Diagnostic Services, Biologics Laboratory, Amsterdam, The Netherlands
| | - Aura A J van Esch
- Inflammatory Bowel Disease Centre, Department of Gastroenterology and Hepatology, Radboud university medical centre, Nijmegen, The Netherlands
| | - Joost P H Drenth
- Inflammatory Bowel Disease Centre, Department of Gastroenterology and Hepatology, Radboud university medical centre, Nijmegen, The Netherlands
| | - Frank Hoentjen
- Inflammatory Bowel Disease Centre, Department of Gastroenterology and Hepatology, Radboud university medical centre, Nijmegen, The Netherlands
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Edlund H, Steenholdt C, Ainsworth MA, Goebgen E, Brynskov J, Thomsen OØ, Huisinga W, Kloft C. Magnitude of Increased Infliximab Clearance Imposed by Anti-infliximab Antibodies in Crohn's Disease Is Determined by Their Concentration. AAPS J 2016; 19:223-233. [PMID: 27739011 DOI: 10.1208/s12248-016-9989-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 09/08/2016] [Indexed: 12/14/2022]
Abstract
Antibodies (Abs) against infliximab (IFX) increase IFX clearance and can result in treatment failure and acute hypersensitivity reactions. However, interpretation of their clinical value is complicated by individual differences in Ab responses and methods used for quantification. The increase in IFX clearance imposed by anti-IFX Abs has generally been evaluated using a binary classification, i.e., positive or negative. This analysis aimed to investigate if anti-IFX Ab concentrations provide a more adequate prediction of alterations in clearance. Data originated from a clinical trial on Crohn's disease patients with IFX treatment failure. The trial was not originally designed for pharmacokinetic analysis. Therefore, published pharmacokinetic models were utilized as priors to enable covariate investigation. The impact of anti-IFX Abs on clearance was assessed using different mathematical relationships and exploiting information from two different quantification assays, measuring semi-quantitative "total" or "unbound neutralizing" concentrations of anti-IFX Ab, respectively. Inclusion of anti-IFX Ab status/concentration improved the model's performance for all investigated relationships. The anti-IFX Ab concentrations were superior to the binary classifications, indicating that the magnitude of increase in IFX clearance imposed by anti-IFX Abs closely relates to their concentration. Furthermore, total anti-IFX Ab concentrations appeared superior to the unbound neutralizing fraction in identifying high clearance individuals. Simulations showed that even at low concentrations, anti-IFX Abs lead to sub-therapeutic IFX concentrations, supporting a need of treatment interventions in all anti-IFX Ab positive patients. The developed model can serve as a basis for further investigations to refine treatment recommendations for patients with anti-IFX Abs.
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Affiliation(s)
- Helena Edlund
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany.,Graduate Research Training Program PharMetrX, Berlin, Germany.,Department of Gastroenterology, Herlev Hospital, Herlev, Denmark
| | | | - Mark A Ainsworth
- Department of Gastroenterology, Herlev Hospital, Herlev, Denmark
| | - Eva Goebgen
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Jørn Brynskov
- Department of Gastroenterology, Herlev Hospital, Herlev, Denmark
| | - Ole Ø Thomsen
- Department of Gastroenterology, Herlev Hospital, Herlev, Denmark
| | - Wilhelm Huisinga
- Institute of Mathematics, Universitaet Potsdam, Potsdam, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany.
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Barnes EL, Allegretti JR. Are Anti-Tumor Necrosis Factor Trough Levels Predictive of Mucosal Healing in Patients With Inflammatory Bowel Disease?: A Systematic Review and Meta-Analysis. J Clin Gastroenterol 2016; 50:733-41. [PMID: 26535480 DOI: 10.1097/MCG.0000000000000441] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
GOALS Our primary goal was to evaluate whether anti-tumor necrosis factor (TNF)-α trough levels above author-determined thresholds are associated with increased rates of mucosal healing among patients with Crohn's disease and ulcerative colitis. BACKGROUND The introduction of anti-TNF agents has considerably advanced the approach to the management of patients with inflammatory bowel disease (IBD). As use of anti-TNF therapy has increased, there has been new interest in algorithms focused on the monitoring of pharmacodynamics and pharmacokinetics to improve outcomes. In addition, there has been an increased focus on mucosal healing as marker of treatment success. STUDY We performed a systematic review and meta-analysis. The studies examined were restricted to randomized controlled trials and cohort studies with a high Jadad or Newcastle-Ottawa score. RESULTS All pooled analyses were based on a random-effects model. Data from 2 randomized controlled trials and 5 observational studies (n=652) were included in the meta-analysis. Among patients with IBD, anti-TNF trough levels above prespecified values were associated with increased rates of mucosal healing (OR=5.57; 95% CI, 3.80-8.15). There was no heterogeneity detected (I=0, Q=5.88, df=6; P=0.436) and there was minimal evidence of publication bias present. CONCLUSIONS There is a strong relationship between anti-TNF trough levels and increased rates of mucosal healing among patients with IBD. Given the increased emphasis on mucosal healing as an outcome in practice and clinical trials, continued focus on the proactive use of pharmacokinetic testing appears warranted.
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