Combination Therapy With Immunomodulators Improves the Pharmacokinetics of Infliximab But Not Vedolizumab or Ustekinumab

BACKGROUND AND AIMS

The aim of this study was to assess how 6-thioguanine nucleotide (6-TGN) levels and use of oral methotrexate relate to the pharmacokinetics of biologics.

METHODS

This was a prospective cohort study including patients with inflammatory bowel diseases on maintenance doses of infliximab, vedolizumab, or ustekinumab on monotherapy or combination with a thiopurine or oral methotrexate. We collected 6-TGN concentrations, biomarker levels, and clinical and endoscopic disease activity. The primary outcomes were infliximab, vedolizumab, and ustekinumab concentrations as well as anti-drug antibodies (ADAs).

RESULTS

A total of 369 patients were recruited (113 infliximab, 133 vedolizumab, and 123 ustekinumab). Patients with 6-TGN levels ≥146 pmol per 8 × 108 red blood cells (RBCs), and those receiving combination therapy with thiopurine or oral methotrexate had significantly higher infliximab concentrations when compared with monotherapy (median levels of 17.4 μg/mL on thiopurine with 6-TGN ≥146 pmol per 8 × 108 RBCs, 17.1 on methotrexate, and 3.9 on infliximab monotherapy; P = .001 for both comparisons). However, there was no association between the use of immunomodulators and 6-TGN concentrations with vedolizumab (median levels of 8.8 on thiopurine with 6-TGN ≥152 pmol per 8 × 108 RBCs, 6.8 on methotrexate, and 10.5 on vedolizumab monotherapy; P > .05 for both comparisons) or ustekinumab median concentrations (median levels of 5.0 on thiopurine with 6-TGN ≥154 pmol per 8 × 108 RBCs, 5.2 on methotrexate and 7.0 on ustekinumab monotherapy; P > .05 for both comparisons). Fourteen (12%) patients had anti-infliximab antibodies, while 1 patient had ADAs in each of the other drug cohorts.

CONCLUSIONS

Achieving higher 6-TGN levels or the use of methotrexate improved the pharmacokinetics of infliximab. Conversely, these data do not support the use of combination therapy to augment pharmacokinetics with vedolizumab or ustekinumab.

Major Lung Resections Using Manual Suturing Versus Staplers During Fiscal Crisis

AbstractObjective: During fiscal crisis there was a period of shortage of staplers in our hospital, which drove us to manual suturing of bronchi and pulmonary vessels during major lung resections. We present our experience during that period in comparison to a subsequent period when staplers became available again.

METHODS

A total of 256 lobectomies and 78 pneumonectomies were performed using manual suturing (group A), between September 2009 and September 2010, and compared regarding surgical outcome to 248 lobectomies and 60 pneumonectomies using staplers (group B), between September 2011 and September 2012.

RESULTS

Although we did not observe statistically significant differences but only a trend towards less operative time, for both lobectomies (p=0.21) and pneumonectomies (p=0.31), we actually noted a 41 and 47 minutes saving of operative time using staplers (group B), in comparison to manual suturing (group A). We also observed a trend towards less morbidity rates in patients of group B, who underwent lobectomy (10.48%), and pneumonectomy (20%), versus patients of group A, who underwent lobectomy (15.62%), and pneumonectomy (30.76%); we did not observe any substantial differences in the other surgical outcome variables, and in patients' demographics comorbidities, and anatomic allocation of surgical procedures performed.

CONCLUSIONS

The use of staplers offers safety with secure bronchial or vascular sealing, and saving of operative time. Their unavailability at an interval during fiscal crisis although it did not affect surgical outcome, revealed their usefulness and value.