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Drobne D, Kurent T, Golob S, Švegl P, Rajar P, Hanžel J, Koželj M, Novak G, Smrekar N, Ferkolj I, Štabuc B. Optimised infliximab monotherapy is as effective as optimised combination therapy, but is associated with higher drug consumption in inflammatory bowel disease. Aliment Pharmacol Ther 2019; 49:880-889. [PMID: 30784100 DOI: 10.1111/apt.15179] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 10/01/2018] [Accepted: 01/16/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Combination treatment with azathioprine for 6-12 months is the preferred strategy for starting infliximab due to improved pharmacokinetics. However, optimised infliximab monotherapy with proactive dose escalations in case of low trough levels is a safer but under-studied alternative. AIM To compare the clinical success and infliximab consumption of combination vs optimised monotherapy strategies. METHODS We studied the clinical success and infliximab consumption of both strategies in 149 patients (94 Crohn's disease; 55 ulcerative colitis) starting infliximab and undergoing intensive drug monitoring assisted treatment optimisation. RESULTS The drug retention rates were similar for optimised monotherapy and combination treatment after induction (96% vs 97%, P = 0.73), after the first year (90% vs 83%, P = 0.23) and at the end of follow-up (74% vs 75%, P = 0.968). Similarly, no differences were observed for steroid use at year 1 (5% vs 14%, P = 0.08) or mucosal healing at the end of follow-up (64% vs 67%, P = 0.8). Higher infliximab consumption (7.6 mg/kg q8 weeks [interquartile range (IQR): 5.9-10.3] vs 6.4 mg/kg q8 weeks [IQR: 5.2-8.0], P = 0.019) combined with lower trough levels (1.7 µg/mL [IQR: 0.3-6.6] vs 5.0 µg/mL [2.5-8.7], P = 0.012) resulted in almost 3-fold higher drug-to-trough ratio (3.9 vs 1.5) in monotherapy compared to combination strategy at year 1. At the end of follow-up, when azathioprine had been discontinued for a median of 14 [IQR: 3-33] months, these differences disappeared. CONCLUSIONS In this study, optimised infliximab monotherapy was as clinically effective as combination therapy but was associated with significantly higher infliximab consumption. The infliximab-sparing effect disappeared after azathioprine withdrawal.
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Affiliation(s)
- David Drobne
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Tina Kurent
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Saša Golob
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Polona Švegl
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Polona Rajar
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Jurij Hanžel
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Matic Koželj
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Gregor Novak
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Nataša Smrekar
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Ivan Ferkolj
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Borut Štabuc
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
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Hanžel J, Sever N, Ferkolj I, Štabuc B, Smrekar N, Kurent T, Koželj M, Novak G, Compernolle G, Tops S, Gils A, Drobne D. Early vedolizumab trough levels predict combined endoscopic and clinical remission in inflammatory bowel disease. United European Gastroenterol J 2019; 7:741-749. [PMID: 31316778 DOI: 10.1177/2050640619840211] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 02/19/2019] [Indexed: 12/18/2022] Open
Abstract
Background The relationship between vedolizumab trough levels and combined endoscopic and clinical remission is unknown. Objective To compare vedolizumab trough levels in patients with and without combined remission within the first year of treatment. Methods We prospectively collected vedolizumab trough levels in 51 consecutive patients (28 Crohn's disease (CD) and 23 ulcerative colitis (UC)) before all infusions up to week 22, and at weeks 38 and 54, with concentrations measured after study completion. Centrally read endoscopy was performed at a median of 46 weeks. The primary outcome was combined endoscopic (CD: Simple endoscopic score for CD (SES-CD) < 4 without ulceration; UC: Mayo endoscopic subscore ≤ 1) and clinical remission (CD: resolution of abdominal pain; UC: resolution of rectal bleeding; both: resolution of altered bowel habit). Results Median vedolizumab trough levels at weeks 6 (25.7 vs 15.6 µg/mL; P = 0.015) and 22 (15.1 vs 4.9 µg/mL; P = 0.001) were higher in patients with combined remission. A threshold of 22 µg/mL at week 6 (area under the curve (AUC) 0.733; 95% confidence interval 0.567-0.899) and 8 µg/mL at week 22 (AUC 0.819; 95% confidence interval 0.692-0.946) predicted combined remission. Conclusion Early vedolizumab trough levels predicted combined endoscopic and clinical remission highlighting their possible use in clinical practice.
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Affiliation(s)
- Jurij Hanžel
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Nejc Sever
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Ivan Ferkolj
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Borut Štabuc
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Nataša Smrekar
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Tina Kurent
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Matic Koželj
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Gregor Novak
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Griet Compernolle
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Sophie Tops
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Ann Gils
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - David Drobne
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
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Drobne D, Kurent T, Golob S, Svegl P, Rajar P, Terzic S, Kozelj M, Novak G, Smrekar N, Plut S, Sever N, Strnisa L, Hanzel J, Brecelj J, Urlep D, Osredkar J, Homan M, Orel R, Stabuc B, Ferkolj I, Smid A. Success and safety of high infliximab trough levels in inflammatory bowel disease. Scand J Gastroenterol 2018; 53:940-946. [PMID: 29987967 DOI: 10.1080/00365521.2018.1486882] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [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] [Indexed: 02/04/2023]
Abstract
OBJECTIVE A prospective trial suggests target infliximab trough levels of 3-7 μg/mL, yet data on additional therapeutic benefits and safety of higher trough levels are scarce. AIM To explore whether high infliximab trough levels (≥7 μg/mL) are more effective and still safe. MATERIAL AND METHODS In this cohort study of 183 patients (109 Crohn's disease and 74 ulcerative colitis) on infliximab maintenance treatment at a tertiary referral center we correlated fecal calprotectin and C-reactive protein to trough levels (426 samples) at different time points during treatment. Rates of infections were compared in quadrimesters (four-month periods) with high trough levels to quadrimesters with trough levels <7 μg/mL during 420 patient-years. RESULTS Fecal calprotectin and C-reactive protein (median [interquartile range]) were lower in patients with high trough levels (fecal calprotectin 66 mg/kg [30-257]; C-reactive protein 3 mg/L [3-3]) compared to trough levels below 7 μg/mL (fecal calprotectin 155 mg/kg [72-474]; C-reactive protein 3 mg/L [3-14.5]) (p < .001). High trough levels were superior also after excluding samples with trough levels <3 μg/mL from analysis. No differences in rates of infections were observed in quadrimesters with high trough levels (16/129 [12.4%]) compared to quadrimesters with trough levels <7 μg/mL (32/344 [9.3%]) (p = .32). Maintaining high trough levels resulted in 32% (interquartile range: 2-54%) increase of infliximab consumption. CONCLUSION High infliximab trough levels provide better control of inflammation in inflammatory bowel disease without increasing the risk of infection.
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Affiliation(s)
- David Drobne
- a Department of Gastroenterology , University Medical Centre Ljubljana , Ljubljana , Slovenia.,b Medical Faculty , University of Ljubljana , Ljubljana , Slovenia
| | - Tina Kurent
- a Department of Gastroenterology , University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Sasa Golob
- a Department of Gastroenterology , University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Polona Svegl
- a Department of Gastroenterology , University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Polona Rajar
- a Department of Gastroenterology , University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Sara Terzic
- c Department of Infectious Diseases , University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Matic Kozelj
- a Department of Gastroenterology , University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Gregor Novak
- a Department of Gastroenterology , University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Natasa Smrekar
- a Department of Gastroenterology , University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Samo Plut
- a Department of Gastroenterology , University Medical Centre Ljubljana , Ljubljana , Slovenia.,b Medical Faculty , University of Ljubljana , Ljubljana , Slovenia
| | - Nejc Sever
- a Department of Gastroenterology , University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Luka Strnisa
- a Department of Gastroenterology , University Medical Centre Ljubljana , Ljubljana , Slovenia.,b Medical Faculty , University of Ljubljana , Ljubljana , Slovenia
| | - Jurij Hanzel
- a Department of Gastroenterology , University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Jernej Brecelj
- b Medical Faculty , University of Ljubljana , Ljubljana , Slovenia.,d Department of Gastroenterology Hepatology and Nutrition , Children's Hospital University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Darja Urlep
- d Department of Gastroenterology Hepatology and Nutrition , Children's Hospital University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Josko Osredkar
- e Clinical Institute of Clinical Chemistry , Biochemistry University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Matjaz Homan
- b Medical Faculty , University of Ljubljana , Ljubljana , Slovenia.,d Department of Gastroenterology Hepatology and Nutrition , Children's Hospital University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Rok Orel
- b Medical Faculty , University of Ljubljana , Ljubljana , Slovenia.,d Department of Gastroenterology Hepatology and Nutrition , Children's Hospital University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Borut Stabuc
- a Department of Gastroenterology , University Medical Centre Ljubljana , Ljubljana , Slovenia.,b Medical Faculty , University of Ljubljana , Ljubljana , Slovenia
| | - Ivan Ferkolj
- a Department of Gastroenterology , University Medical Centre Ljubljana , Ljubljana , Slovenia.,b Medical Faculty , University of Ljubljana , Ljubljana , Slovenia
| | - Alojz Smid
- a Department of Gastroenterology , University Medical Centre Ljubljana , Ljubljana , Slovenia.,b Medical Faculty , University of Ljubljana , Ljubljana , Slovenia
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Pernat Drobež C, Ferkolj I, Potočnik U, Repnik K. Crohn's Disease Candidate Gene Alleles Predict Time to Progression from Inflammatory B1 to Stricturing B2, or Penetrating B3 Phenotype. Genet Test Mol Biomarkers 2018; 22:143-151. [PMID: 29446656 DOI: 10.1089/gtmb.2017.0210] [Citation(s) in RCA: 8] [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] [Indexed: 12/15/2022] Open
Abstract
AIM Crohn's disease (CD) patients are mostly diagnosed with the uncomplicated inflammatory form of disease; however, the majority will progress to complicated stricturing or penetrating disease over time. It is important to identify patients at risk for disease progression at an early stage. The aim of our study was to examine the role of 33 candidate CD genes as possible predictors of disease progression and their influence on time to progression from an inflammatory to a stricturing or penetrating phenotype. METHODS Patients with an inflammatory phenotype at diagnosis were followed for 10 years and 33 CD-associated polymorphisms were genotyped. To test for association with CD, 449 healthy individuals were analyzed as the control group. RESULTS Ten years after diagnosis, 39.1% of patients had not progressed beyond an inflammatory phenotype, but 60.9% had progressed to complicated disease, with average time to progression being 5.91 years. Association analyses of selected single nucleotide polymorphisms (SNPs) confirmed associations with CD for 12 SNPs. Furthermore, seven loci were associated with disease progression, out of which SNP rs4263839 in the gene TNFSF15 showed the strongest association with disease progression and the frameshift mutation rs2066847 in the gene NOD2 showed the strongest association with time to progression. CONCLUSIONS The results of our study identified specific genetic biomarkers as useful predictors of both disease progression and speed of disease progression in patients with CD.
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Affiliation(s)
- Cvetka Pernat Drobež
- 1 Department of Gastroenterology, University Medical Centre Maribor , Maribor, Slovenia
| | - Ivan Ferkolj
- 2 Department of Gastroenterology, Division of Internal Medicine, University Medical Centre Ljubljana , Ljubljana, Slovenia
| | - Uroš Potočnik
- 3 Center for Human Molecular Genetics and Pharmacogenomics, Faculty of Medicine, University of Maribor , Maribor, Slovenia .,4 Laboratory for Biochemistry, Molecular Biology and Genomics, Faculty for Chemistry and Chemical Engineering, University of Maribor , Maribor, Slovenia
| | - Katja Repnik
- 3 Center for Human Molecular Genetics and Pharmacogenomics, Faculty of Medicine, University of Maribor , Maribor, Slovenia .,4 Laboratory for Biochemistry, Molecular Biology and Genomics, Faculty for Chemistry and Chemical Engineering, University of Maribor , Maribor, Slovenia
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Affiliation(s)
- Žiga Rotar
- 1 University Medical Centre Ljubljana, Department of Rheumatology, Ljubljana, Slovenia
| | - Ivan Ferkolj
- 2 University Medical Centre Ljubljana, Department of Gastroenterology, Ljubljana, Slovenia
| | - Matija Tomšič
- 1 University Medical Centre Ljubljana, Department of Rheumatology, Ljubljana, Slovenia.,3 Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Alojzija Hočevar
- 1 University Medical Centre Ljubljana, Department of Rheumatology, Ljubljana, Slovenia
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Repnik K, Koder S, Skok P, Ferkolj I, Potočnik U. Transferrin Level Before Treatment and Genetic Polymorphism in HFE Gene as Predictive Markers for Response to Adalimumab in Crohn’s Disease Patients. Biochem Genet 2016; 54:476-486. [DOI: 10.1007/s10528-016-9734-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 04/13/2016] [Indexed: 12/19/2022]
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Deželak M, Repnik K, Koder S, Ferkolj I, Potočnik U. A Prospective Pharmacogenomic Study of Crohn's Disease Patients during Routine Therapy with Anti-TNF-α Drug Adalimumab: Contribution of ATG5, NFKB1, and CRP Genes to Pharmacodynamic Variability. OMICS 2016; 20:296-309. [PMID: 27096233 DOI: 10.1089/omi.2016.0005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Crohn's disease is often treated with the anti-tumor necrosis factor-α drug adalimumab. However, about 20%-40% of patients do not display adequate therapeutic response. We prospectively evaluated, during a routine therapy of Crohn's disease patients, the candidate autophagy-related genes ATG12 and ATG5 and the inflammation-related genes NFKB1, NFKBIA, and CRP as potential predictors of adalimumab treatment response (pharmacodynamics). The associations of haplotypes and SNPs in these genes with response to drug therapy, biochemical parameters, and body mass were determined at baseline and after 4, 12, 20, and 30 weeks of therapy. Association analysis showed that haplotypes defined with the SNPs rs9373839 and rs510432 in ATG5 gene were significantly associated with positive response to therapy (p < 0.002). In addition, allele C and genotypes CC and CT of the rs1130864 in the CRP gene were positively associated with therapeutic response (p < 0.002). To the best of our knowledge, this is the first report that supports the association of SNPs in ATG5 and CRP genes with response to adalimumab therapy in Crohn's disease. Further study of these biological pathways in larger and independent clinical samples is warranted as novel streams of research on precision medicine and diagnostics for Crohn's disease.
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Affiliation(s)
- Matjaž Deželak
- 1 Centre for Human Molecular Genetics and Pharmacogenomics, Faculty of Medicine, University of Maribor , Maribor, Slovenia
| | - Katja Repnik
- 1 Centre for Human Molecular Genetics and Pharmacogenomics, Faculty of Medicine, University of Maribor , Maribor, Slovenia .,2 Laboratory for Biochemistry, Molecular Biology and Genomics, Faculty for Chemistry and Chemical Engineering, University of Maribor , Maribor, Slovenia
| | - Silvo Koder
- 3 University Medical Centre Maribor , Maribor, Slovenia
| | - Ivan Ferkolj
- 4 University Medical Centre Ljubljana , Ljubljana, Slovenia
| | - Uroš Potočnik
- 1 Centre for Human Molecular Genetics and Pharmacogenomics, Faculty of Medicine, University of Maribor , Maribor, Slovenia .,2 Laboratory for Biochemistry, Molecular Biology and Genomics, Faculty for Chemistry and Chemical Engineering, University of Maribor , Maribor, Slovenia
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Koder S, Repnik K, Ferkolj I, Pernat C, Skok P, Weersma RK, Potočnik U. Genetic polymorphism in ATG16L1 gene influences the response to adalimumab in Crohn's disease patients. Pharmacogenomics 2015; 16:191-204. [PMID: 25712183 DOI: 10.2217/pgs.14.172] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [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: 02/07/2023] Open
Abstract
AIM To see if SNPs could help predict response to biological therapy using adalimumab (ADA) in Crohn's disease (CD). MATERIALS & METHODS IBDQ index and CRP levels were used to monitor therapy response. We genotyped 31 CD-associated genes in 102 Slovenian CD patients. RESULTS The strongest association for treatment response defined as decrease in CRP levels was found for ATG16L1 SNP rs10210302. Additional SNPs in 7 out of 31 tested CD-associated genes (PTGER4, CASP9, IL27, C11orf30, CCNY, IL13, NR1I2) showed suggestive association with ADA response. CONCLUSION Our results suggest ADA response in CD patients is genetically predisposed by SNPs in CD risk genes and suggest ATG16L1 as most promising candidate gene for drug response in ADA treatment. Original submitted 24 September 2014; Revision submitted 1 December 2014.
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Affiliation(s)
- Silvo Koder
- University Medical Centre Maribor, Ljubljanska 5, Maribor, Slovenia
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Zidar N, Ferkolj I, Tepeš K, Štabuc B, Kojc N, Uršič T, Petrovec M. Diagnosing cytomegalovirus in patients with inflammatory bowel disease--by immunohistochemistry or polymerase chain reaction? Virchows Arch 2015; 466:533-9. [PMID: 25701481 DOI: 10.1007/s00428-015-1741-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [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: 11/02/2014] [Revised: 01/31/2015] [Accepted: 02/08/2015] [Indexed: 12/16/2022]
Abstract
Cytomegalovirus (CMV) reactivation is a common complication in patients with inflammatory bowel diseases (IBD), particularly in those with steroid-resistant ulcerative colitis. It is usually diagnosed by histopathologic and immunohistochemical examination of the colon biopsy. The introduction of quantitative, real-time polymerase chain reaction (qPCR) has been recommended to improve the sensitivity, but there is little consensus on how to use it. We compared the two methods in samples from resected bowel of patients with IBD. Twelve patients with IBD who had undergone bowel resection were analysed for CMV, using qPCR and immunohistochemistry. In all cases, tissue samples from the base and the edge of ulcers and from uninvolved mucosa were obtained. The highest densities of CMV-positive cells were found in samples from the base of ulcers (immunohistochemistry 0-0.47 positive cells/mm(2); qPCR 10-3809 viral copies/mg) or the edge of ulcers (immunohistochemistry 0.06-0.32 positive cells/mm(2); qPCR 35-1049 viral copies/mg). In samples of uninvolved mucosa, immunohistochemistry was negative, whereas qPCR was either negative or showed very low values (0-3 viral copies/mg). We conclude that both immunohistochemistry and qPCR can be successfully used for diagnosing CMV reactivation in patients with IBD. The base and the edge of ulcers are the optimal sites for endoscopic biopsies. The density of CMV-positive cells was low and their distribution within the colon uneven. It therefore seems that the number of sampled biopsies and/or the number of investigated levels is more important that the choice of diagnostic method.
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Affiliation(s)
- Nina Zidar
- Institute of Pathology, Faculty of Medicine, University of Ljubljana, Korytkova 2, 1000, Ljubljana, Slovenia,
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Ferkolj I. How to improve the safety of biologic therapy in Crohn's disease. J Physiol Pharmacol 2009; 60 Suppl 7:67-70. [PMID: 20388947] [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] [Subscribe] [Scholar Register] [Received: 10/15/2009] [Accepted: 12/11/2009] [Indexed: 05/29/2023]
Abstract
Short- and long-term anti tumor necrosis factor-alpha (TNF-alpha) therapy in Crohn's disease is generally well tolerated. However, clinicians must be vigilant for the occurrence of infrequent but serious events. Antibodies to infliximab interfere with the safety and efficacy of the drug and may lead to infusion reactions, loss of response, and delayed serum sickness-like reactions. The optimal strategy to overcome the production of antibodies is systematic maintenance treatment. The most effective way to minimize the risk of opportunistic infection is to vaccinate the patients and to avoid the use of corticosteroids. All patients should receive varicella vaccination, annual influenza vaccination (also pandemic influenza A - H1N1), and pneumococcal vaccination every 3 to 5 years. In addition, HPV vaccine should be administered to young females, and hepatitis B vaccine to HBV seronegative patients. Unlike corticosteroids, infliximab does not pose an increased risk for serious infection. Treatment with anti TNF-alpha agents increases the risk of activation of latent TB. Therefore, all patients should be screened for TB infection before starting with therapy. The use of anti TNF-alpha agents in combination with immunomodulators is associated with an increased risk of non-Hodgkin's lymphoma, but the absolute rate remains low. There is no evidence that other malignancies and death rates in patients treated with anti TNF-alpha strategies are increased. Reported data from 300 pregnant women treated with infliximab have not shown any untoward effects of treatment on pregnancy outcome.
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Affiliation(s)
- I Ferkolj
- Department of Gastroenterology, Division of Internal Medicine, University Medical Centre Ljubljana, Slovenia.
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Groselj D, Grabec I, Seme K, Ihan A, Ferkolj I. Prediction of clinical response to anti-TNF treatment by oral parameters in Crohn's disease. Hepatogastroenterology 2008; 55:112-119. [PMID: 18507089] [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] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND/AIMS The aim of our work was to predict the clinical response of Crohn's disease (CD) patients to anti-tumor necrosis factor (TNF) treatment by dental, periodontal, and oral mucosa parameters. METHODOLOGY In 5 patients with luminal CD and in 9 patients with fistulizing CD, oral symptoms and signs before drug administration were assessed by 27 parameters, including: a) Decayed-, missing-, filled -, healthy -, nonvital -, root canal filled -, total number of - and impacted teeth; b) Oral ulcers, swelling of lips and cheeks, recurrent oral aphthae and hyperplasia of the mucosa; c) Width of keratinized gingiva, probing depth, gingival margin, clinical attachment level, bleeding on probing, plaque index, gingival index and gingival crevicular fluid (GCF) volume; d) The percentage of 8 morphotypes of subgingival plaque detected by darkfield microscopy (DFM), with the total number of bacteria examined. A new statistical prediction method has been introduced. RESULTS At time lapse of 8 weeks after infliximab administration the prediction quality estimated from 8 optimal parameters attained a value of 0.63. However, with time lapse increasing to 3 months, the prediction quality decreased to 0.21, indicating that oral and response parameters became more statistically independent. CONCLUSIONS This indicates that the oral state parameters could provide a sound basis for predicting the response of patients to infliximab administration.
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Affiliation(s)
- Dusan Groselj
- Department of Dental Medicine, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
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Ferkolj I, Hocevar A, Golouh R, Dolenc Voljc M. Infliximab for treatment of resistant pyoderma gangrenosum associated with Crohn's disease. Acta Dermatovenerol Alp Pannonica Adriat 2006; 15:173-177. [PMID: 17982610] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
We present the case of an 18-year-old woman with Crohn's disease manifested by diffuse abdominal pain, bloody diarrhea accompanied by arthralgia, and swelling of large joints. On the lateral aspect of her right ankle there was an hemorrhagic, necrotic bullous lesion measuring 3 x 4 cm, surrounded by cutaneous inflammation and erythema. Biopsy showed a neutrophilic abscess-like ulcerative skin inflammation, which was diagnosed as pyoderma gangrenosum. The patient was treated with high doses of parenteral methylprednisolone, but her condition failed to improve and infliximab, a TNF-alpha blocking agent, was instituted. An immediate response of Crohn's disease was observed and, over the next 5 weeks, the ulcer on her right ankle also healed completely.
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Affiliation(s)
- Ivan Ferkolj
- Department of Gastroenterology, University Medical Centre, Division of Internal Medicine, Japljeva 2, 1000 Ljubljana, Slovenia.
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Ferkolj I, Ihan A, Markovic S, Veceric Z, Pohar M. Infliximab reduces the number of activated mucosal lymphocytes in patients with Crohn's disease. J Gastrointestin Liver Dis 2006; 15:231-5. [PMID: 17013447] [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] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
BACKGROUND Infliximab is an effective treatment for Crohn's disease in patients with poor prior response to conventional therapy. The mechanism by which infliximab induces clinical improvement is not completely known. AIM The aim of the study was to investigate the influence of infliximab on immunological parameters in peripheral blood and inflamed intestinal mucosa. METHODS Twenty-five patients with Crohn's disease (11 with luminal and 14 with fistular form) underwent treatment with infliximab. The lymphocyte populations from the peripheral blood and the inflamed intestinal mucosa were analysed by flow cytometry before treatment and 14 days later. RESULTS After treatment, the peripheral blood analysis showed a significant increase in the percentage of CD19 cells and the concentrations of CD3, CD4, CD8 and activated (HLA DR positive) T cells, while the percentage of NK cells was reduced. In the inflamed mucosa, a significant decrease in the percentage of activated T cells and expression of HLA I molecules by epithelial cells was noted. CONCLUSIONS Infliximab profoundly downregulates inflammation in the intestinal mucosa of patients with Crohn's disease. This effect is manifested by a reduction of activated T cells, main producers of proinflammatory cytokines, in the inflamed mucosa.
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Affiliation(s)
- Ivan Ferkolj
- University Medical Centre, Division of Internal Medicine, Department of Gastroenterology, Japljeva 2, 1000 Ljubljana, Slovenia.
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Ferkolj I, Ihan A, Markovic S. CD19+ in intestinal mucosa predict the response to infliximab in Crohn's disease. Hepatogastroenterology 2005; 52:1128-33. [PMID: 16001645] [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] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
BACKGROUND/AIMS Infliximab is an effective treatment for Crohn's disease, yet about 30% of patients have a weak or no response. The aim of the study was to determine if the likelihood of a patient achieving complete remission 3 months after treatment with infliximab can be predicted from immunological parameters measured in peripheral blood and inflamed intestinal mucosa before the treatment. METHODOLOGY 25 patients with Crohn's disease resistant to conventional therapy underwent treatment with infliximab. Samples of peripheral blood and inflamed intestinal mucosa were analyzed by flow-cytometry before infliximab administration. The clinical response was evaluated after 3 months. RESULTS At 3 months post-treatment, 11 (44%) patients were in complete remission, while 14 (56%) had no remission. Logistic regression analysis revealed that 50% of patients having 2.29% of CD19+ cells in inflamed intestinal mucosa may be expected to achieve complete remission. If the proportion of CD19+ cells in the inflamed mucosa is 5%, the probability of the patient achieving complete remission following treatment rises to 85%. CONCLUSIONS This is the first study which found that a high percentage of CD19+ cells in the inflamed intestinal mucosa of a patient with Crohn's disease may predict long remission after infliximnab therapy.
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Affiliation(s)
- Ivan Ferkolj
- Department of Gastroenterology, Division of Internal Medicine, University Medical Centre, Ljubljana, Slovenia.
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Potocnik U, Ferkolj I, Glavac D, Dean M. Polymorphisms in multidrug resistance 1 (MDR1) gene are associated with refractory Crohn disease and ulcerative colitis. Genes Immun 2005; 5:530-9. [PMID: 15505619 DOI: 10.1038/sj.gene.6364123] [Citation(s) in RCA: 137] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
We used coding and noncoding polymorphisms evenly spaced across the ABCB1/MDR1 gene to perform association analysis in Slovenian patients with inflammatory bowel diseases and to obtain haplotype structure and patterns of linkage disequilibrium (LD) in the MDR1 gene. A disease association study was performed in 307 IBD patients, including 144 patients with ulcerative colitis (UC) and 163 patients with Crohn's disease (CD), and 355 healthy controls. Here we report an association between MDR1 alleles, polymorphisms and haplotypes and refractory CD patients, who do not respond to standard therapy, including patients who develop fistulas. We also report an association with UC and MDR1 polymorphisms in a Slovenian population. Haplotypes significantly associated with diseases were defined by single-nucleotide polymorphisms (SNPs) in exons 12 (1236 C>A), 21(A893S), and 26 (3435 C>T). In addition, two intronic SNPs in LD with the disease haplotype, one in intron 13 (rs2235035) and another in intron 16 (rs1922242), were significantly associated with refractory Crohn (P=0.026, odds ratio (OR) 2.7 and P=0.025, OR 2.8, respectively), as well as with UC (P=0.006, OR 1.8 and P=0.026, OR 1.9, respectively). Our results suggest that MDR1 is a potential target for therapy in refractory CD patients and in patients with UC.
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Affiliation(s)
- U Potocnik
- Laboratory of Molecular Genetics, Institute of Pathology, Medical Faculty, Ljubljana, Slovenia
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