Clinical profiles and outcomes in patients with ulcerative colitis receiving standard and higher-than-standard doses of vedolizumab: findings from a real-world study in Europe

OBJECTIVE

Vedolizumab is an antibody targeting α4β7 integrin used in the treatment of ulcerative colitis (UC). Patients are commonly prescribed higher-than-standard doses if treatment response is inadequate, but little is known about the drivers and impact of increased dosing. Our objective was to use real-world data to describe vedolizumab dosages in current clinical practice, patient characteristics, physicians' reasons for prescribing vedolizumab, and physician treatment satisfaction.

METHODS

Data were derived from the Adelphi Real World UC vedolizumab Chart Review, a cross-sectional survey of gastroenterologists and their UC patients, conducted in France, Germany, Italy, Spain, and the United Kingdom between December 2022 and March 2023. Gastroenterologists provided data on patient demographics, clinical characteristics, treatment and vedolizumab dosage history, reasons for dose choice, and treatment satisfaction.

RESULTS

Data were returned on 448 patients by 112 gastroenterologists. Overall, 83.5% of patients were on a standard vedolizumab dose and 10.3% were on a higher-than-standard dose. The worsening of symptoms was the most cited reason for higher doses. Most reported symptoms at survey were fatigue, abdominal distention or pain, diarrhea, and bowel urgency, with the latter particularly in higher-than-standard dose patients. Patients on higher-than-standard dose had high rates of mild (37.0%) or moderate (26.1%) disease, and low rates of remission (33.8%). Physicians were dissatisfied with treatment control for 2.7% of standard and 26.1% of higher-than-standard dose patients.

CONCLUSIONS

Over 10% of patients were receiving a higher-than-standard dose of vedolizumab, but despite this were found to have suboptimal clinical outcomes and low physician satisfaction.

Fate of polycyclic aromatic compounds from diluted bitumen spilled into freshwater limnocorrals

Diluted bitumens (dilbits) are produced by mixing highly viscous bitumen with lighter petroleum products to facilitate transport. The unique physical and chemical properties of dilbit may affect the environmental fate and effects of dilbit-derived chemical compounds when spilled. To further explore this, we monitored experimental spills of Cold Lake Winter Blend (CLWB) dilbit for 70 days in limnocorrals installed in a freshwater boreal lake. A regression design with 2 controls and 7 treatments was used to assess the fate and behaviour of polycyclic aromatic compounds (PACs) as they partitioned from the dilbit into the air, water column and sediments. Treatments ranged from 1.5 to 180 L of CLWB, resulting in oil:water ratios ranging between 1:71000 to 1:500 (v:v). We began to detect elevated concentrations of PACs as early as 6 h post-addition in the air, 12 h post-addition in the water column, and 15-28 d post-addition in the sediments. By the end of the experiment, concentrations of PACs had largely declined in the water column but remained elevated in the sediments. Our results demonstrate that under conditions typical of temperate boreal lakes, only a small proportion of PACs from dilbit enters the aquatic system, but even so, may produce concentrations of ecotoxicological concern, especially in the sediments, which is the ultimate sink for dilbit-derived PACs.

Endocrine and physiological responses of hatchling American kestrels (Falco sparverius) following embryonic exposure to technical short-chain chlorinated paraffins (C10-13)

Short chain chlorinated paraffins (SCCPs) are complex mixtures of polychlorinated n-alkanes, shown to bioaccumulate but with unknown effects in wild birds. The present study examined development-related effects of SCCPs on captive American kestrels (Falco sparverius) treated in ovo on embryonic day (ED) 5 by injection with technical Chloroparaffin® (C_10-13, 55.5% Cl) at environmentally relevant nominal (measured) concentrations of 10 (10), 50 (29) or 100 (97) ng ΣSCCP/g egg ww, and artificially incubated until hatching (ED27-ED29). The SCCP concentrations measured in the yolk sacs of the hatchling kestrels bracketed concentrations reported in the eggs of wild birds. Uptake and deposition of these SCCPs differed between male and female hatchlings, with only males showing differences in SCCP concentrations, being highest in the high-dose males than each of the other male groups. Embryonic exposure to SCCPs suppressed glandular total thyroxine (TT4) (20-33%) and reduced circulating triiodothyronine (TT3) (37-40%) in male hatchlings only when compared to control males, but had no effect on glandular TT3 or circulating TT4 in male or female kestrels. Histological assessments of thyroid glands showed that both sexes experienced significant structural changes indicative of gland activation. These thyroid glandular changes and the variations in SCCP concentrations were related to circulating TT3 in female hatchlings. Hepatic deiodinase enzyme (D1, D2) activities were stable and no SCCP-related changes were observed in hatching success, hatchling size, or immune organ size. However, several of the thyroid function indicators were correlated with hatchling size and smaller bursas and spleens, possibly indirectly through SCCP-induced changes in thyroid function. Because changes in thyroid function were evident at concentrations measured in wild bird eggs, similar changes may occur in wild nestlings. The potential impact of these changes on thyroid-mediated growth and survival in wild birds requires further investigation.

Changes in thyroid function of nestling tree swallows (Tachycineta bicolor) in relation to polycyclic aromatic compounds and other environmental stressors in the Athabasca Oil Sands Region

In the Canadian Athabasca Oil Sands Region (AOSR), nestling tree swallows (Tachycineta bicolor) raised near mining-related activities accumulated greater concentrations of polycyclic aromatic compounds (PACs) that contributed to their poorer condition, growth, and reproductive success. Here, we report changes in thyroid function of the same 14 day old (do) nestlings (N ≤ 68) at these mining-related sites (OS1, OS2) compared to reference nestlings (REF1), and in relation to multiple environmental stressors that influence avian thyroid function. Thyroid function was compromised for OS1 nestlings but generally comparable between OS2 and REF1 chicks. In 2012, circulating total triiodothyronine (TT3) and thyroxine (TT4) were similar among all nestlings. The OS1 chicks had more active thyroid glands based on histological endpoints. Hepatic T4 outer-ring deiodinase (T4-ORD) activity was suppressed in OS1 and OS2 chicks. Despite inter-annual differences, OS1 chicks continued experiencing compromised thyroid function with significantly higher circulating TT4 and more active thyroid glands in 2013. The OS2 chicks had less active thyroid glands, which conceivably contributed to their suppressed growth (previously reported) relative to the heavier OS1 nestlings with more active thyroid glands. Thyroid gland activity was more influenced by the chicks' accumulation of (muscle), than exposure (feces) to naphthalene, C2-naphthalenes, and C1-fluorenes. Of four major volatile organic contaminants, sulfur dioxide (SO₂) primarily influenced thyroid gland activity and structure, supporting previous findings with captive birds. When collectively considering environmental-thyroidal stressors, chicks had a greater thyroidal response when they experienced colder temperatures, accumulated more C2-naphthalenes, and consumed aquatic-emerging insects with higher PAC burdens than terrestrial insects (carbon (δ¹³C)). We hypothesize that the more active thyroid glands and higher circulating TT4 of the OS1 chicks supported their growth and survival despite having the highest PAC burdens, whereas the lack of thyroid response in the OS2 chicks combined with high PAC burdens, contributed to their smaller size, poorer condition and poorer survival.

Myocardial oxidative stress changes during compensated right heart failure in rats

The suggested role of oxidative stress in the pathogenesis of heart failure is largely based on utilizing left heart failure models. The present study on rats evaluated changes in antioxidants as well as oxidative stress in relation to hemodynamic function subsequent to the right heart failure induced by monocrotaline (50 mg/kg, i.p.). During the post-injection period, monocrotaline (MCT)-treated rats demonstrated a persistent growth depression. Two to three weeks after the injection, MCT-treated rats showed signs of fatigue, peripheral cyanosis and dyspnea. In these rats, right heart hypertrophy was confirmed by a significant increase in right ventricular weight as well as right ventricle to body weight ratio. In MCT-treated rats, there was also a significant increase in right ventricular systolic as well as end diastolic pressures. No change in lung and liver wet/dry weight ratios between MCT-treated and control animals was observed. Based on the hemodynamic data as well as other clinical observations, the functional stage achieved was compensated heart failure. Myocardial antioxidant enzymes, catalase, glutathione peroxidase and superoxide dismutase, in the MCT-treated rats were not different compared to control rats. Vitamin E levels were significantly depressed in the RV and there was no change in retinol levels. There was a significant increase in lipid hydroperoxide concentrations in MCT-treated rats as compared to the control group. These data provide evidence that right heart failure is associated with an increase in oxidative stress.

Regional differences in non-enzymatic antioxidants in the heart under control and oxidative stress conditions

Antioxidants are known to play an important role in mitigating oxidative stress injury. Regional concentrations of non-enzymatic antioxidants, redox ratio and lipid peroxides were studied in normal, ischemic and ischemic-reperfused rat hearts. Isolated perfused rat hearts were made globally ischemic for 45 min and reperfused for 15 min. Right ventricular wall (RVW), septum (S) and left ventricular wall (LVW) from control, ischemic (I) and reperfused (I-R) hearts were analysed. Tocopherol, retinol and ascorbic acid concentrations in different regions of perfused control hearts were not different. Reduced glutathione (GSH) was significantly lower in the RVW, while S and LVW had about three-fold higher levels. Oxidized glutathione (GSSG) was lower in the RVW and most concentrated in the LVW. The GSH:GSSG ratio was highest in the septum while RVW and LVW had similar values. Lipid hydroperoxide (LPx) concentrations in the three regions of control hearts were not different from each other. In I and I-R hearts, vitamin E declined in all three regions but the loss was significant only in the septum in the I group and in the septum and LVW of the I-R group. Vitamin A showed significant loss in all three regions of the I-R group. Vitamin C declined significantly only in the RVW of the I-R group. GSH increased in the RVW of the I and I-R groups compared to controls. GSSG was increased in the RVW and septum of the I group and in all regions of the I-R group. The redox ratio, GSH:GSSG, decreased in all regions of both I and I-R groups. LPx were increased in the septum of the I group and in all regions of the I-R group. Despite unique regional differences in non-enzymatic antioxidants, a comparable increase in LPx in the I-R group and similar extent of reduction in the redox ratio in different regions of the I and I-R groups, suggest that each myocardial region may use different antioxidant mechanisms to withstand oxidative stress.

The role of oxidative stress in the genesis of heart disease

Although researchers in radiation and cancer biology have known about the existence of free radicals and their potential role in pathobiology for several decades, cardiac biologists only began to take notice of these noxious species in the 1970s. Exponential growth of free radical research occurred after the discovery of superoxide dismutase in 1969. This antioxidant enzyme is responsible for the dismutation of superoxide radical--a free radical chain initiator. A fine balance between free radicals and a variety of endogenous antioxidants is believed to exist. Any disturbance in this equilibrium in favour of free radicals causes an increase in oxidative stress and initiates subcellular changes leading to cardiomyopathy and heart failure. Our knowledge about the role of free radicals in the pathogenesis of cardiac dysfunction is fast approaching the point where newer therapies employing antioxidants are in sight.

Modulation of adriamycin-induced changes in serum free fatty acids, albumin and cardiac oxidative stress

Adriamycin-induced cardiomyopathic changes are prevented by combination therapy with probucol. These beneficial effects are suggested to be due to a combination of antioxidant as well as lipid-lowering effects of probucol. In the present study, we compared the effects of probucol (PROB) with that of lovastatin (LOV), a lipid-lowering drug, and trolox (TRO), an antioxidant, on adriamycin (ADR)-induced subchronic in vivo changes in serum free fatty acids (FFA), serum albumin and myocardial reduced (GSH) and oxidized (GSSG) glutathione in rats. ADR caused a significant increase in FFA, decrease in albumin, and an increase in FFA/albumin. PROB and LOV modulated the increases in FFA and FFA/albumin, while TRO was without any effect. ADR reduced myocardial GSH, increased GSSG and decreased GSH/GSSG. Only PROB caused significant improvement in GSH and normalized GSSG levels. It is suggested that these modulatory effects of probucol may also contribute in the beneficial effects of this drug against adriamycin-induced cardiomyopathy and congestive heart failure.