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Atia O, Friss C, Focht G, Magen Rimon R, Ledderman N, Greenfeld S, Ben-Tov A, Loewenberg Weisband Y, Matz E, Gorelik Y, Chowers Y, Dotan I, Turner D. Durability of the First Biologic in Children and Adults With Ulcerative Colitis: A Nationwide Study from the epi-IIRN. Inflamm Bowel Dis 2024:izae067. [PMID: 38578929 DOI: 10.1093/ibd/izae067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Indexed: 04/07/2024]
Abstract
BACKGROUND In this nationwide study, our objective was to compare the durability of first-line biologics in ulcerative colitis (UC), categorized into monotherapy and combotherapy with immunomodulators. METHODS We utilized data from the nationwide epi-IIRN cohort from 2005 to 2020. Durability was defined as consistent treatment without surgery. Comparisons were based on stringent propensity score-matching. RESULTS We included 15 111 patients with UC, of whom 2322 (15%) received biologics, with a median follow-up of 7.0 years (interquartile range, 3.8-11.0). The durability rate was similar between pediatric-onset and adults after 1 and 5 years from initiation of treatment (72% and 43% vs 71% and 43%, respectively; P = .8). Durability of adalimumab vs infliximab after 1 or 5 years was similar, whether prescribed as monotherapy (65%/46% vs 63%/33%, respectively; n = 182 matched pairs, P = .3) or combotherapy (78%/56% vs 91%/58%, respectively; n = 46 matched pairs, P = .4). Durability of infliximab was higher as combotherapy (85%/50%) vs monotherapy (69%/42%; n = 174 matched pairs, P = .007), while it was similar for adalimumab (80%/52% vs 74%/52%; n = 53 matched pairs, P = .4). The durability rate was similar for vedolizumab monotherapy (77%/56%) compared with adalimumab monotherapy (69%/52%; n = 125 matched patients, P = .1), and infliximab monotherapy (73%/55% vs 62%/44%; n = 78 matched patients, P = .1). However, combotherapy of antitumor necrosis factors (TNFs) had longer durability than vedolizumab (85%/50% vs 75%/43%, respectively; n = 131 matched pairs, P = .02). CONCLUSION After 5 years of treatment, 43% of the patients with UC sustained their first biologic, with similar durability in pediatric and adult-onset onset disease. Anti-TNFs had similar durability to vedolizumab and superior durability when prescribed as combotherapy.
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Affiliation(s)
- Ohad Atia
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Chagit Friss
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Gili Focht
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ramit Magen Rimon
- Pediatric Gastroenterology & Nutrition Institute, Ruth Rappaport Children's Hospital, Rambam Health Care Campus and the Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | | | - Shira Greenfeld
- Kahn-Sagol-Maccabi Research and Innovation Center, Maccabi Healthcare Services, Tel Aviv, Israel and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Ben-Tov
- Kahn-Sagol-Maccabi Research and Innovation Center, Maccabi Healthcare Services, Tel Aviv, Israel and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Eran Matz
- Leumit Health Services, Tel-Aviv, Israel
| | - Yuri Gorelik
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology and the Gastroenterology Institute, Rambam Health Care Campus, Haifa, Israel
| | - Yehuda Chowers
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology and the Gastroenterology Institute, Rambam Health Care Campus, Haifa, Israel
| | - Iris Dotan
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel and the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dan Turner
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
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Carasso S, Zaatry R, Hajjo H, Kadosh-Kariti D, Ben-Assa N, Naddaf R, Mandelbaum N, Pressman S, Chowers Y, Gefen T, Jeffrey KL, Jofre J, Coyne MJ, Comstock LE, Sharon I, Geva-Zatorsky N. Inflammation and bacteriophages affect DNA inversion states and functionality of the gut microbiota. Cell Host Microbe 2024; 32:322-334.e9. [PMID: 38423015 PMCID: PMC10939037 DOI: 10.1016/j.chom.2024.02.003] [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: 04/01/2023] [Revised: 12/11/2023] [Accepted: 02/06/2024] [Indexed: 03/02/2024]
Abstract
Reversible genomic DNA inversions control the expression of numerous gut bacterial molecules, but how this impacts disease remains uncertain. By analyzing metagenomic samples from inflammatory bowel disease (IBD) cohorts, we identified multiple invertible regions where a particular orientation correlated with disease. These include the promoter of polysaccharide A (PSA) of Bacteroides fragilis, which induces regulatory T cells (Tregs) and ameliorates experimental colitis. The PSA promoter was mostly oriented "OFF" in IBD patients, which correlated with increased B. fragilis-associated bacteriophages. Similarly, in mice colonized with a healthy human microbiota and B. fragilis, induction of colitis caused a decline of PSA in the "ON" orientation that reversed as inflammation resolved. Monocolonization of mice with B. fragilis revealed that bacteriophage infection increased the frequency of PSA in the "OFF" orientation, causing reduced PSA expression and decreased Treg cells. Altogether, we reveal dynamic bacterial phase variations driven by bacteriophages and host inflammation, signifying bacterial functional plasticity during disease.
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Affiliation(s)
- Shaqed Carasso
- Department of Cell Biology and Cancer Science, Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Rappaport Technion Integrated Cancer Center (RTICC), Haifa 32000, Israel
| | - Rawan Zaatry
- Department of Cell Biology and Cancer Science, Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Rappaport Technion Integrated Cancer Center (RTICC), Haifa 32000, Israel
| | - Haitham Hajjo
- Department of Cell Biology and Cancer Science, Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Rappaport Technion Integrated Cancer Center (RTICC), Haifa 32000, Israel
| | - Dana Kadosh-Kariti
- Department of Cell Biology and Cancer Science, Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Rappaport Technion Integrated Cancer Center (RTICC), Haifa 32000, Israel
| | - Nadav Ben-Assa
- Department of Cell Biology and Cancer Science, Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Rappaport Technion Integrated Cancer Center (RTICC), Haifa 32000, Israel
| | - Rawi Naddaf
- Department of Cell Biology and Cancer Science, Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Rappaport Technion Integrated Cancer Center (RTICC), Haifa 32000, Israel
| | - Noa Mandelbaum
- Department of Cell Biology and Cancer Science, Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Rappaport Technion Integrated Cancer Center (RTICC), Haifa 32000, Israel
| | - Sigal Pressman
- Department of Gastroenterology, Rambam Health Care Campus, Haifa 3109601, Israel; Clinical Research Institute, Rambam Health Care Campus, Haifa 3109601, Israel
| | - Yehuda Chowers
- Department of Gastroenterology, Rambam Health Care Campus, Haifa 3109601, Israel; Clinical Research Institute, Rambam Health Care Campus, Haifa 3109601, Israel; Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa 32000, Israel
| | - Tal Gefen
- Department of Cell Biology and Cancer Science, Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Rappaport Technion Integrated Cancer Center (RTICC), Haifa 32000, Israel
| | - Kate L Jeffrey
- Moderna, Inc., Cambridge, MA 02139, USA; Center for the Study of Inflammatory Bowel Disease, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital Research Institute, Boston, MA 02114, USA; Harvard Medical School, Boston, MA 02115, USA; Program in Immunology, Harvard Medical School, Boston, MA 02115, USA
| | - Juan Jofre
- Department of Genetics, Microbiology and Statistics, School of Biology, University of Barcelona, Avda. Diagonal 643 08028, Barcelona, Spain
| | - Michael J Coyne
- Duchossois Family Institute and Department of Microbiology, University of Chicago, Chicago, IL, USA
| | - Laurie E Comstock
- Duchossois Family Institute and Department of Microbiology, University of Chicago, Chicago, IL, USA
| | - Itai Sharon
- Migal-Galilee Research Institute, P.O. Box 831, Kiryat Shmona 11016, Israel; Faculty of Sciences and Technology, Tel-Hai Academic College, Upper Galilee 1220800, Israel
| | - Naama Geva-Zatorsky
- Department of Cell Biology and Cancer Science, Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Rappaport Technion Integrated Cancer Center (RTICC), Haifa 32000, Israel; CIFAR, MaRS Centre, West Tower 661, Suite 505, Toronto, ON M5G 1M1, Canada.
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Atia O, Friss C, Focht G, Magen Rimon R, Ledderman N, Greenfeld S, Ben-Tov A, Loewenberg Weisband Y, Matz E, Gorelik Y, Chowers Y, Dotan I, Turner D. Durability of the First Biologic in Patients with Crohn's Disease: A Nationwide Study from the epi-IIRN. J Crohns Colitis 2024; 18:38-46. [PMID: 37465992 DOI: 10.1093/ecco-jcc/jjad121] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 04/14/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND In this nationwide study we aimed to compare the durability of the first initiated biologic in Crohn's disease [CD], stratified by monotherapy and combotherapy. METHODS We used data from the epi-IIRN cohort, which includes 98% of the Israeli inflammatory bowel disease population [2005-2020]. Durability was defined as consistent treatment without surgery or added medications [except for combination therapy with thiopurines or methotrexate]. All comparisons were based on stringent propensity-score matching and paired time-to-event analyses. RESULTS A total of 19 264 patients with CD were included, of whom 7452 [39%] received biologics with a median follow-up of 6.8 years (interquartile range [IQR] 3.6-10.7). Time to biologics decreased gradually from 6.7 years [IQR 2.7-10.4] in 2005 to 0.2 years [0.07-0.23] in 2020. The durability of the first biologic after 1 and 3 years was higher with adalimumab monotherapy [88%/61%] than vedolizumab monotherapy [81%/59%; n = 394 matched patients, p = 0.04] and similar between infliximab monotherapy and vedolizumab monotherapy [65%/43%; n = 182 matched patients, p = 0.1]. Durability was higher in adalimumab monotherapy vs infliximab monotherapy [83%/62% vs 71%/48% at 1/3 years; p <0.001] and it was similar in adalimumab monotherapy vs infliximab combotherapy [87%/63% vs 80%/58%, respectively; p = 0.1]. Durability was higher in combotherapy compared with monotherapy for both infliximab [85%/64% vs 67%/43%, respectively; n = 496 matched pairs, p <0.001], and adalimumab [93%/76% vs 82%/62%, respectively; n = 540 matched pairs, p <0.001]. CONCLUSION Durability of the first biologic in CD was highest for adalimumab monotherapy. Combotherapy further increased the durability of adalimumab and infliximab. Unless otherwise indicated, our data may support using anti-tumour necrosis factors [TNFs] as first-line biologics in CD, particularly adalimumab if monotherapy is advised.
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Affiliation(s)
- Ohad Atia
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Chagit Friss
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Gili Focht
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ramit Magen Rimon
- Pediatric Gastroenterology & Nutrition Institute, Ruth Rappaport Children's Hospital, Rambam Health Care Campus and the Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | | | - Shira Greenfeld
- Kahn-Sagol-Maccabi Research and Innovation Center, Maccabi Healthcare Services, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Ben-Tov
- Kahn-Sagol-Maccabi Research and Innovation Center, Maccabi Healthcare Services, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Eran Matz
- Leumit Health Services, Tel-Aviv, Israel
| | - Yuri Gorelik
- Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology and the Gastroenterology Institute, Rambam Health Care Campus, Haifa, Israel
| | - Yehuda Chowers
- Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology and the Gastroenterology Institute, Rambam Health Care Campus, Haifa, Israel
| | - Iris Dotan
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dan Turner
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
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Gerassy-Vainberg S, Starosvetsky E, Gaujoux R, Blatt A, Maimon N, Gorelik Y, Pressman S, Alpert A, Bar-Yoseph H, Dubovik T, Perets B, Katz A, Milman N, Segev M, Chowers Y, Shen-Orr SS. A personalized network framework reveals predictive axis of anti-TNF response across diseases. Cell Rep Med 2024; 5:101300. [PMID: 38118442 PMCID: PMC10829759 DOI: 10.1016/j.xcrm.2023.101300] [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: 02/21/2023] [Revised: 08/20/2023] [Accepted: 10/31/2023] [Indexed: 12/22/2023]
Abstract
Personalized treatment of complex diseases has been mostly predicated on biomarker identification of one drug-disease combination at a time. Here, we use a computational approach termed Disruption Networks to generate a data type, contextualized by cell-centered individual-level networks, that captures biology otherwise overlooked when performing standard statistics. This data type extends beyond the "feature level space", to the "relations space", by quantifying individual-level breaking or rewiring of cross-feature relations. Applying Disruption Networks to dissect high-dimensional blood data, we discover and validate that the RAC1-PAK1 axis is predictive of anti-TNF response in inflammatory bowel disease. Intermediate monocytes, which correlate with the inflammatory state, play a key role in the RAC1-PAK1 responses, supporting their modulation as a therapeutic target. This axis also predicts response in rheumatoid arthritis, validated in three public cohorts. Our findings support blood-based drug response diagnostics across immune-mediated diseases, implicating common mechanisms of non-response.
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Affiliation(s)
- Shiran Gerassy-Vainberg
- Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 32000, Israel; Department of Gastroenterology, Rambam Health Care Campus, Haifa 3109601, Israel
| | - Elina Starosvetsky
- Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 32000, Israel
| | - Renaud Gaujoux
- Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 32000, Israel; CytoReason, Tel Aviv 67012, Israel
| | - Alexandra Blatt
- Department of Gastroenterology, Rambam Health Care Campus, Haifa 3109601, Israel
| | - Naama Maimon
- Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 32000, Israel; Department of Gastroenterology, Rambam Health Care Campus, Haifa 3109601, Israel
| | - Yuri Gorelik
- Department of Gastroenterology, Rambam Health Care Campus, Haifa 3109601, Israel
| | - Sigal Pressman
- Department of Gastroenterology, Rambam Health Care Campus, Haifa 3109601, Israel; Clinical Research Institute, Rambam Health Care Campus, Haifa 3109601, Israel
| | - Ayelet Alpert
- Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 32000, Israel
| | - Haggai Bar-Yoseph
- Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 32000, Israel; Department of Gastroenterology, Rambam Health Care Campus, Haifa 3109601, Israel
| | - Tania Dubovik
- Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 32000, Israel
| | - Benny Perets
- Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 32000, Israel
| | | | - Neta Milman
- Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 32000, Israel
| | - Meital Segev
- Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 32000, Israel
| | - Yehuda Chowers
- Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 32000, Israel; Department of Gastroenterology, Rambam Health Care Campus, Haifa 3109601, Israel; Clinical Research Institute, Rambam Health Care Campus, Haifa 3109601, Israel.
| | - Shai S Shen-Orr
- Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 32000, Israel.
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Atia O, Friss C, Focht G, Magen Rimon R, Ledderman N, Ben-Tov A, Loewenberg Weisband Y, Matz E, Gorelik Y, Chowers Y, Dotan I, Turner D. Durability of Adalimumab and Infliximab in Children With Crohn's Disease: A Nationwide Comparison From the epi-IIRN Cohort. Inflamm Bowel Dis 2024:izad301. [PMID: 38190498 DOI: 10.1093/ibd/izad301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND In a nationwide cohort, we aimed to compare the durability of infliximab and adalimumab as first biologic treatment in children with Crohn's disease (CD), stratified as combotherapy or monotherapy. METHODS We used data from the epi-IIRN cohort that includes all patients with inflammatory bowel diseases in Israel. Durability was defined as consistent treatment without surgery or treatment escalation. All comparisons followed stringent propensity-score matching in Cox proportional hazard models. RESULTS Of the 3487 children diagnosed with CD since 2005, 2157 (62%) received biologics (1127 [52%] infliximab, 964 [45%] adalimumab and 52 [2%] vedolizumab as first biologic), representing a higher proportion than that among adults diagnosed during the same time period (5295 of 15 776 [34%]; P < .001). Time from diagnosis to initiation of biologic was shorter in pediatric-onset compared with adult-onset disease (median time during the last 3 years was 2.7 months [interquartile range 1.2-5.4] vs 5.2 months [2.6-8.9]; P < .001). The durability of adalimumab monotherapy after 1 and 5 years from initiation of treatment was better than infliximab monotherapy (79%/54% vs 67%/37%, respectively; n = 452 matched children; hazard ratio [HR], 1.7; 95% confidence interval [CI], 1.3-2.3; P < .001), while in those treated with combotherapy, durability was similar (94%/66% with infliximab vs 90%/54% with adalimumab; n = 100; HR, 1.7; 95% CI, 0.9-3.3; P = .1). Durability was higher in children treated with infliximab combotherapy vs infliximab monotherapy (87%/45% vs 75%/39%; n = 440; HR, 1.4; 95% CI, 1.1-1.8; P = .01). The durability of adalimumab monotherapy was similar to infliximab combotherapy (83%/53% vs 89%/56%, respectively; n = 238; HR, 0.9; 95% CI, 0.7-1.2; P = .4). CONCLUSION Our results support using adalimumab monotherapy as a first-line biologic in children with CD. When infliximab is used, combotherapy may be advantageous over monotherapy.
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Affiliation(s)
- Ohad Atia
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Israel
| | - Chagit Friss
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Israel
| | - Gili Focht
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Israel
| | - Ramit Magen Rimon
- Pediatric Gastroenterology & Nutrition institute, Ruth Rappaport Children's Hospital, Rambam Medical Center, Faculty of Medicine, Technion, Haifa, Israel
| | | | - Amir Ben-Tov
- Kahn Sagol Maccabi Research and Innovation Center, Maccabi Healthcare Services, Tel-Aviv, Israel
- The Faculty of Medicine, Tel Aviv University, Israel
| | | | - Eran Matz
- Leumit Health Services, Tel-Aviv, Israel
| | - Yuri Gorelik
- Technion Israel Institute of Technology, Department of Gastroenterology, Rambam Healthcare Campus, Bruce Rappaport School of Medicine, Haifa, Israel
| | - Yehuda Chowers
- Technion Israel Institute of Technology, Department of Gastroenterology, Rambam Healthcare Campus, Bruce Rappaport School of Medicine, Haifa, Israel
| | - Iris Dotan
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel
- The Faculty of Medicine, Tel Aviv University, Israel
| | - Dan Turner
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Israel
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Gorelik Y, Ghersin I, Shlon D, Friss C, Lujan R, Loewenberg Weisband Y, Greenfeld S, Kariv R, Ledderman N, Matz E, Dotan I, Bar-Yoseph H, Chowers Y, Turner D. Association of Antibiotic Use with Durability of Biologic Agents in Inflammatory Bowel Disease: a Report from the epi-IIRN. J Crohns Colitis 2023; 17:1410-1417. [PMID: 37084088 DOI: 10.1093/ecco-jcc/jjad070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Indexed: 04/22/2023]
Abstract
BACKGROUND Different antibiotic classes were reported to have variable effects on immunogenicity towards anti-tumour necrosis factor [TNF] agents. However, the impact of antibiotic administration on biologic treatment durability was not investigated. We aimed to assess the association between antibiotic treatment and persistence of different classes of biologic therapy in inflammatory bowel disease [IBD] patients. METHODS Data from the epi-IIRN, a nationwide registry of all Israeli IBD patients were analysed. All patients who filled a prescription of either infliximab, adalimumab, vedolizumab, or ustekinumab, were included. Treatment cessation was defined as drug discontinuation of at least 6 months. Macrolides, cephalosporins, fluoroquinolones, and penicillins with beta-lactamase inhibitors were selected as primary exposure variables. Survival analysis was performed using marginal structural models for each drug separately. RESULTS In all 13 513 IBD patients, with a total of 39 600 patient-years, were included. Significant differences of overall treatment persistence were demonstrated, with highest persistence rates for ustekinumab and the lowest for infliximab treatment. Macrolides were found to be significantly associated with reduced risk of infliximab cessation (adjusted hazard ratio [aHR] 0.72, 95% CI 0.62-0.89]. Fluoroquinolones and cephalosporins were associated with an elevated risk of adalimumab treatment cessation [aHR 1.33, 95% CI 1.22-1.46; and aHR 1.20, 95% CI 1.08-1.34, respectively]. No significant effects of the studied antibiotics were observed in ustekinumab and vedolizumab users. CONCLUSIONS Specific antibiotic classes are associated with duration of anti-TNF treatment, but not with durability of vedolizumab or ustekinumab treatments. Further research is required to study the effect of specific antibiotics on response to biologics.
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Affiliation(s)
- Yuri Gorelik
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Itai Ghersin
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Deema Shlon
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Chagit Friss
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, Hebrew University of Jerusalem, Israel
| | - Rona Lujan
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, Hebrew University of Jerusalem, Israel
| | | | - Shira Greenfeld
- Maccabi Health Services, Tel-Aviv, Israel
- The Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Revital Kariv
- Maccabi Health Services, Tel-Aviv, Israel
- The Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Natan Ledderman
- Meuhedet Health Services, Meuhedet Research Institue, Tel-Aviv, Israel
| | - Eran Matz
- Leumit Health Services, Leumit Research Institue, Tel-Aviv, Israel
| | - Iris Dotan
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel
| | - Haggai Bar-Yoseph
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Yehuda Chowers
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
- Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Dan Turner
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, Hebrew University of Jerusalem, Israel
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7
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Bar-Yoseph H, Blatt A, Gerassy S, Pressman S, Mousa A, Sabo E, Waterman M, Ungar B, Ben-Horin S, Chowers Y. Differential Serum-intestinal Dynamics of Infliximab and Adalimumab in Inflammatory Bowel Disease Patients. J Crohns Colitis 2022; 16:884-892. [PMID: 34849649 DOI: 10.1093/ecco-jcc/jjab208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Therapeutic drug monitoring is used to guide anti-tumour necrosis factor [TNF] therapy. However, the associations between serum drug levels [SDL], TNF-bound, and free anti-TNF in the target tissue are incompletely defined. We aimed to assess the interactions between these parameters in inflammatory bowel disease [IBD] patients. METHODS: ENZYME-LINKED IMMUNOSORBENT assays [ELISA assays] were used to detect free drug and TNF-drug complexes in intestinal tissues. Concurrent SDL, anti-drug antibodies [ADA], pharmacotherapy, clinical response, endoscopic appearance, and histological severity were determined. Comparisons between anti-TNFs and paired inflamed/non-inflamed tissue were performed. Variables were correlated and potential interactions detected using multivariate analysis. RESULTS A total of 95 biopsies taken from 49 anti-TNF treated IBD patients [26 receiving infliximab and 23 adalimumab] were studied. Free drug levels were higher in inflamed compared with non-inflamed paired specimens. Tissue free-drug and TNF-drug complexes levels were higher in adalimumab-treated patients. In adalimumab-treated patients, SDL were correlated with free drug, but not TNF-drug complex levels, in both inflamed and non-inflamed segments. In infliximab-treated patients, higher SDL were associated with the presence of tissue free drug in both inflamed and non-inflamed segments, whereas TNF-drug complexes were mostly detected in non-inflamed but not in inflamed tissue. In the presence of ADA, neither free drug nor TNF-infliximab complexes were measured in the tissue. Tissue levels did not correlate well with clinical, endoscopic, or histological scores. CONCLUSIONS SDL correlated with tissue free drug levels; however, different dynamics were observed for TNF-drug complex levels. Infliximab and adalimumab tissue drug dynamics differ. Better understanding of these interactions may allow future therapeutic optimisation.
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Affiliation(s)
- Haggai Bar-Yoseph
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel.,Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Alexandra Blatt
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Shiran Gerassy
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Sigal Pressman
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Amjad Mousa
- Department of Internal Medicine H, Rambam Health Care Campus, Haifa, Israel
| | - Edmond Sabo
- Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel.,Department of Pathology, Carmel Medical Center, Haifa, Israel
| | - Matti Waterman
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel.,Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Bella Ungar
- Department of Gastroenterology, Chaim Sheba Medical Center, Ramat-Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shomron Ben-Horin
- Department of Gastroenterology, Chaim Sheba Medical Center, Ramat-Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yehuda Chowers
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel.,Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel.,Clinical Research Institute, Rambam Health Care Campus, Haifa, Israel
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8
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Atia O, Orlanski-Meyer E, Lujan R, Ledderman N, Greenfeld S, Kariv R, Daher S, Yanai H, Loewenberg Weisband Y, Gabay H, Matz E, Nevo D, Israeli E, Schwartz D, Chowers Y, Dotan I, Turner D. Improved Outcomes of Paediatric and Adult Crohn's Disease and Association With Emerging Use of Biologics-A Nationwide Study From the Epi-IIRN. J Crohns Colitis 2022; 16:778-785. [PMID: 34791083 DOI: 10.1093/ecco-jcc/jjab204] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [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: 12/24/2022]
Abstract
BACKGROUND The effectiveness of biologics for improving long-term outcomes in patients with Crohn's disease [CD] is still controversial. In this nationwide study, we aimed to evaluate trends of long-term outcomes in all CD patients in Israel during the biologics era. METHODS Trends of outcomes were analysed using data from the four Israeli health maintenance organisations, covering 98% of the population; joinpoint regression models were used to explore changes of these trends over 2005 to 2019. RESULTS A total of 16 936 patients were diagnosed with CD in Israel since 2005 (2932 [17%] paediatric onset, 14 004 [83%] adult onset) with 114 947 person-years of follow-up. The cumulative rate of any CD related surgery was 5%, 9%, 11%, and 14% at 1, 3, 5, and 10 years from diagnosis. The increase in use of biologics was sharp (from 8.9% to 36%; average annual percent change [AAPC], 14.3%), and the time to biologics was shorter in recent years (median time of 4.8 [1.9-8.1] years in those diagnosed in 2005-2008 compared with 0.5 [0.2-1.1] years in those diagnosed in 2015-2018; p < 0.001). A significant decrease was noted in the hazard of hospitalisations (1.3 [0.1-4.6] years compared with 0.2 [0.02-0.9] years; p < 0.001), steroid dependency (1.5 [0.2-5.4] years compared with 0.1 [0.02-0.4] years; p < 0.001), and intestinal surgeries [4.7 [1.6-8.2] years compared with 0.6 [0.2-1.4] years; p < 0.001), but not of perianal surgery (4.2 [1.1-7.7] years compared with 0.6 [0.2-1.4] years; p = 0.2). Outcomes were consistently worse in paediatric onset compared with adults. CONCLUSIONS The rates of hospitalisations, steroid dependency, and intestinal resections decreased in association with increased use of biologics both in children and in adults, but not the rate of perianal surgeries.
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Affiliation(s)
- Ohad Atia
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, Hebrew University of Jerusalem, Israel
| | - Esther Orlanski-Meyer
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, Hebrew University of Jerusalem, Israel
| | - Rona Lujan
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, Hebrew University of Jerusalem, Israel
| | - Natan Ledderman
- Meuhedet Health Services, Meuhedet Research Institute, Tel-Aviv, Israel
| | - Shira Greenfeld
- Maccabi Health Services, Maccabi Research Institute, Tel-Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Revital Kariv
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, Hebrew University of Jerusalem, Israel
| | - Saleh Daher
- Israel Defense Forces Medical Corps, Department of Medical Services, Jerusalem, Israel.,Hadadsah-Hebrew University Medical Center, Institute of Gastrointestinal and Liver Diseases, Jerusalem, Israel
| | - Henit Yanai
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel, and Sackler Faculty of Medicine, Tel Aviv University, Israel
| | | | - Hagit Gabay
- Clalit Health Services, Clalit Research Institute, Tel-Aviv, Israel
| | - Eran Matz
- Leumit Health Services, Leumit Research Institute, Tel-Aviv, Israel
| | - Daniel Nevo
- Department of Statistics and Operations Research, Tel Aviv University, Israel
| | - Eran Israeli
- Institute of Gastroenterology and Liver Diseases, E. Wolfson Medical Center, Holon, Israel, and Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Doron Schwartz
- Department of Gastroenterology and Hepatology, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Yehuda Chowers
- Technion Israel Institute of Technology, Department of Gastroenterology, Rambam Healthcare Campus, Bruce Rappaport School of Medicine, Haifa, Israel
| | - Iris Dotan
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel, and Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Dan Turner
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, Hebrew University of Jerusalem, Israel
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9
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Atia O, Orlanski-Meyer E, Lujan R, Ledderman N, Greenfeld S, Kariv R, Daher S, Yanai H, Loewenberg Weisband Y, Gabay H, Matz E, Nevo D, Ollech J, Zittan E, Israeli E, Schwartz D, Chowers Y, Dotan I, Turner D. Colectomy Rates did not Decrease in Paediatric- and Adult-Onset Ulcerative Colitis During the Biologics Era: A Nationwide Study From the epi-IIRN. J Crohns Colitis 2022; 16:796-803. [PMID: 34904163 DOI: 10.1093/ecco-jcc/jjab210] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/04/2021] [Accepted: 11/16/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND It is still of debate whether the advent of biologics has been associated with a change in the natural history of ulcerative colitis [UC]. In this nationwide study we evaluated trends of long-term outcomes in all patients diagnosed with UC in Israel during the biologic era. METHODS Data in the epi-IIRN cohort were retrieved from the four Israeli Health Maintenance Organizations covering 98% of the population, and linked to the Ministry of Health prospective registry on surgeries and hospitalizations. Joinpoint Regression and Kaplan-Meier survival analyses were used, reporting annual average percentage change [AAPC] for each outcome. RESULTS A total of 13 231 patients were diagnosed with UC since 2005 (1426 [11%] paediatric-onset, 10 310 [78%] adults, 1495 [11%] elderly) with 93 675 person-years of follow-up. The probabilities of surgery after 1, 3 and 5 years from diagnosis were 1.1, 2.3 and 4.1%, respectively, and the corresponding rates of hospitalizations were 22, 33 and 41%. The overall utilization of biologics in UC increased from 0.1% in 2005 to 9.6% in 2019 [AAPC 22.1%] and they were prescribed earlier during the disease course (median of 5.6 years [interquartile range 2.8-9.1] in 2005-2008 vs 0.8 years [0.4-1.5] in 2015-2018; p < 0.001]. Annual rates of surgeries [AAPC -1.3; p = 0.6] and steroid-dependency [AAPC -1.2; p = 0.3] remained unchanged, while rates of hospitalizations slightly decreased [AAPC -1.2; p < 0.001]. Outcomes were consistently worse in paediatric-onset disease than in adults, despite higher utilization of biologics [28% vs 12%, respectively; p < 0.001]. CONCLUSION During the biologic era rates of surgeries and steroid-dependency have remained unchanged in patients with UC, while rates of hospitalizations have slightly decreased.
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Affiliation(s)
- Ohad Atia
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Israel
| | - Esther Orlanski-Meyer
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Israel
| | - Rona Lujan
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Israel
| | | | - Shira Greenfeld
- Maccabi Health Services, Tel-Aviv, Israel and the Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Revital Kariv
- Maccabi Health Services, Tel-Aviv, Israel and the Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Saleh Daher
- Israel Defense Forces Medical Corps, Department of Medical Services, Jerusalem, Israel and Hadadsah-Hebrew University Medical Center, Institute of Gastrointestinal and Liver Diseases, Jerusalem, Israel
| | - Henit Yanai
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel, and the Sackler Faculty of Medicine, Tel Aviv University, Israel
| | | | - Hagit Gabay
- Clalit Health Services, Clalit Research Institute, Tel-Aviv, Israel
| | - Eran Matz
- Leumit Health Services, Tel-Aviv, Israel
| | - Daniel Nevo
- Department of Statistics and Operations Research, Tel Aviv University, Israel
| | - Jacob Ollech
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel, and the Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Eran Zittan
- The Abraham and Sonia Rochlin IBD Unit, Department of Gastroenterology, Emek Medical Center, Afula, Israel, and Rappaport Faculty of Medicine Technion-Israel Institute of Technology, Haifa, Israel
| | - Eran Israeli
- Institute of Gastroenterology and Liver Diseases, E. Wolfson Medical Center, Holon, Israel, and the Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Doron Schwartz
- Department of Gastroenterology and Hepatology, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Yehuda Chowers
- Technion Israel Institute of Technology, Department of Gastroenterology, Rambam Healthcare Campus, Bruce Rappaport School of Medicine, Haifa, Israel
| | - Iris Dotan
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel, and the Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Dan Turner
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Israel
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10
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Lichtenstein L, Koslowsky B, Ben Ya’acov A, Avni-Biron I, Ovadia B, Ben-Bassat O, Naftali T, Kopylov U, Haberman Y, Eran HB, Eliakim R, Lahat-Zok A, Hirsch A, Zittan E, Maharshak N, Waterman M, Israeli E, Goren I, Ollech JE, Yanai H, Ungar B, Avidan B, Ben Hur D, Melamud B, Segol O, Shalem Z, Dotan I, Odes SH, Ben-Horin S, Snir Y, Milgrom Y, Broide E, Goldin E, Delgado S, Ron Y, Cohen NA, Maoz E, Zborovsky M, Odeh S, Abu Freha N, Shachar E, Chowers Y, Engel T, Reiss-Mintz H, Segal A, Zinger A, Bar-Gil Shitrit A. COVID-19 in Patients with Inflammatory Bowel Disease: The Israeli Experience. Vaccines (Basel) 2022; 10:vaccines10030376. [PMID: 35335008 PMCID: PMC8950285 DOI: 10.3390/vaccines10030376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/23/2022] [Accepted: 02/24/2022] [Indexed: 01/08/2023] Open
Abstract
Background: Crohn’s disease (CD) and ulcerative colitis (UC) are chronic, immune-mediated inflammatory bowel diseases (IBD) affecting millions of people worldwide. IBD therapies, designed for continuous immune suppression, often render patients more susceptible to infections. The effect of the immune suppression on the risk of coronavirus disease-19 (COVID-19) is not fully determined yet. Objective: To describe COVID-19 characteristics and outcomes and to evaluate the association between IBD phenotypes, infection outcomes and immunomodulatory therapies. Methods: In this multi-center study, we prospectively followed IBD patients with proven COVID-19. De-identified data from medical charts were collected including age, gender, IBD type, IBD clinical activity, IBD treatments, comorbidities, symptoms and outcomes of COVID-19. A multivariable regression model was used to examine the effect of immunosuppressant drugs on the risk of infection by COVID-19 and the outcomes. Results: Of 144 IBD patients, 104 (72%) were CD and 40 (28%) were UC. Mean age was 32.2 ± 12.6 years. No mortalities were reported. In total, 94 patients (65.3%) received biologic therapy. Of them, 51 (54%) at escalated doses, 10 (11%) in combination with immunomodulators and 9 (10%) with concomitant corticosteroids. Disease location, behavior and activity did not correlate with the severity of COVID-19. Biologics as monotherapy or with immunomodulators or corticosteroids were not associated with more severe infection. On the contrary, patients receiving biologics had significantly milder infection course (p = 0.001) and were less likely to be hospitalized (p = 0.001). Treatment was postponed in 34.7% of patients until recovery from COVID-19, without consequent exacerbation. Conclusion: We did not witness aggravated COVID-19 outcomes in patients with IBD. Patients treated with biologics had a favorable outcome.
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Affiliation(s)
- Lev Lichtenstein
- Clalit Health Services, Tel Aviv, Israel; (L.L.); (E.M.); (M.Z.)
| | - Benjamin Koslowsky
- Digestive Diseases Institute, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; (B.K.); (A.B.Y.); (E.G.)
| | - Ami Ben Ya’acov
- Digestive Diseases Institute, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; (B.K.); (A.B.Y.); (E.G.)
| | - Irit Avni-Biron
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel; (I.A.-B.); (H.B.E.); (I.G.); (J.E.O.); (H.Y.); (I.D.); (Y.S.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; (T.N.); (U.K.); (Y.H.); (R.E.); (A.L.-Z.); (A.H.); (N.M.); (E.I.); (B.U.); (B.A.); (B.M.); (Z.S.); (S.H.O.); (S.B.-H.); (E.B.); (Y.R.); (N.A.C.); (E.S.); (T.E.); (H.R.-M.)
| | - Baruch Ovadia
- Department of Gastroenterology and Hepatology, Hillel Yaffe Medical Center, Hadera, Israel;
| | | | - Timna Naftali
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; (T.N.); (U.K.); (Y.H.); (R.E.); (A.L.-Z.); (A.H.); (N.M.); (E.I.); (B.U.); (B.A.); (B.M.); (Z.S.); (S.H.O.); (S.B.-H.); (E.B.); (Y.R.); (N.A.C.); (E.S.); (T.E.); (H.R.-M.)
- Department of Gastroenterology and Liver Diseases, Meir Medical Center, Kfar Saba, Israel
| | - Uri Kopylov
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; (T.N.); (U.K.); (Y.H.); (R.E.); (A.L.-Z.); (A.H.); (N.M.); (E.I.); (B.U.); (B.A.); (B.M.); (Z.S.); (S.H.O.); (S.B.-H.); (E.B.); (Y.R.); (N.A.C.); (E.S.); (T.E.); (H.R.-M.)
- Department of Gastroenterology, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Yael Haberman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; (T.N.); (U.K.); (Y.H.); (R.E.); (A.L.-Z.); (A.H.); (N.M.); (E.I.); (B.U.); (B.A.); (B.M.); (Z.S.); (S.H.O.); (S.B.-H.); (E.B.); (Y.R.); (N.A.C.); (E.S.); (T.E.); (H.R.-M.)
- Department of Gastroenterology, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Hagar Banai Eran
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel; (I.A.-B.); (H.B.E.); (I.G.); (J.E.O.); (H.Y.); (I.D.); (Y.S.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; (T.N.); (U.K.); (Y.H.); (R.E.); (A.L.-Z.); (A.H.); (N.M.); (E.I.); (B.U.); (B.A.); (B.M.); (Z.S.); (S.H.O.); (S.B.-H.); (E.B.); (Y.R.); (N.A.C.); (E.S.); (T.E.); (H.R.-M.)
| | - Rami Eliakim
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; (T.N.); (U.K.); (Y.H.); (R.E.); (A.L.-Z.); (A.H.); (N.M.); (E.I.); (B.U.); (B.A.); (B.M.); (Z.S.); (S.H.O.); (S.B.-H.); (E.B.); (Y.R.); (N.A.C.); (E.S.); (T.E.); (H.R.-M.)
- Department of Gastroenterology, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Adi Lahat-Zok
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; (T.N.); (U.K.); (Y.H.); (R.E.); (A.L.-Z.); (A.H.); (N.M.); (E.I.); (B.U.); (B.A.); (B.M.); (Z.S.); (S.H.O.); (S.B.-H.); (E.B.); (Y.R.); (N.A.C.); (E.S.); (T.E.); (H.R.-M.)
- Department of Gastroenterology, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Ayal Hirsch
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; (T.N.); (U.K.); (Y.H.); (R.E.); (A.L.-Z.); (A.H.); (N.M.); (E.I.); (B.U.); (B.A.); (B.M.); (Z.S.); (S.H.O.); (S.B.-H.); (E.B.); (Y.R.); (N.A.C.); (E.S.); (T.E.); (H.R.-M.)
- Sourasky Medical Center, Tel Aviv, Israel
| | - Eran Zittan
- Inflammatory Bowel Disease Unit, Ha’emek Medical Center, Faculty of Medicine, Israel Institute of Technology, Afula, Israel;
- Faculty of Medicine, Israel Institute of Technology, Haifa, Israel; (M.W.); (D.B.H.); (Y.C.)
| | - Nitsan Maharshak
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; (T.N.); (U.K.); (Y.H.); (R.E.); (A.L.-Z.); (A.H.); (N.M.); (E.I.); (B.U.); (B.A.); (B.M.); (Z.S.); (S.H.O.); (S.B.-H.); (E.B.); (Y.R.); (N.A.C.); (E.S.); (T.E.); (H.R.-M.)
- Sourasky Medical Center, Tel Aviv, Israel
| | - Matti Waterman
- Faculty of Medicine, Israel Institute of Technology, Haifa, Israel; (M.W.); (D.B.H.); (Y.C.)
- Rambam Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eran Israeli
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; (T.N.); (U.K.); (Y.H.); (R.E.); (A.L.-Z.); (A.H.); (N.M.); (E.I.); (B.U.); (B.A.); (B.M.); (Z.S.); (S.H.O.); (S.B.-H.); (E.B.); (Y.R.); (N.A.C.); (E.S.); (T.E.); (H.R.-M.)
- Department of Gastroenterology and Liver Diseases, Wolfson Medical Center, Holon, Israel
| | - Idan Goren
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel; (I.A.-B.); (H.B.E.); (I.G.); (J.E.O.); (H.Y.); (I.D.); (Y.S.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; (T.N.); (U.K.); (Y.H.); (R.E.); (A.L.-Z.); (A.H.); (N.M.); (E.I.); (B.U.); (B.A.); (B.M.); (Z.S.); (S.H.O.); (S.B.-H.); (E.B.); (Y.R.); (N.A.C.); (E.S.); (T.E.); (H.R.-M.)
| | - Jacob E. Ollech
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel; (I.A.-B.); (H.B.E.); (I.G.); (J.E.O.); (H.Y.); (I.D.); (Y.S.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; (T.N.); (U.K.); (Y.H.); (R.E.); (A.L.-Z.); (A.H.); (N.M.); (E.I.); (B.U.); (B.A.); (B.M.); (Z.S.); (S.H.O.); (S.B.-H.); (E.B.); (Y.R.); (N.A.C.); (E.S.); (T.E.); (H.R.-M.)
| | - Henit Yanai
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel; (I.A.-B.); (H.B.E.); (I.G.); (J.E.O.); (H.Y.); (I.D.); (Y.S.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; (T.N.); (U.K.); (Y.H.); (R.E.); (A.L.-Z.); (A.H.); (N.M.); (E.I.); (B.U.); (B.A.); (B.M.); (Z.S.); (S.H.O.); (S.B.-H.); (E.B.); (Y.R.); (N.A.C.); (E.S.); (T.E.); (H.R.-M.)
| | - Bella Ungar
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; (T.N.); (U.K.); (Y.H.); (R.E.); (A.L.-Z.); (A.H.); (N.M.); (E.I.); (B.U.); (B.A.); (B.M.); (Z.S.); (S.H.O.); (S.B.-H.); (E.B.); (Y.R.); (N.A.C.); (E.S.); (T.E.); (H.R.-M.)
- Department of Gastroenterology, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Benjamin Avidan
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; (T.N.); (U.K.); (Y.H.); (R.E.); (A.L.-Z.); (A.H.); (N.M.); (E.I.); (B.U.); (B.A.); (B.M.); (Z.S.); (S.H.O.); (S.B.-H.); (E.B.); (Y.R.); (N.A.C.); (E.S.); (T.E.); (H.R.-M.)
- Department of Gastroenterology, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Dana Ben Hur
- Faculty of Medicine, Israel Institute of Technology, Haifa, Israel; (M.W.); (D.B.H.); (Y.C.)
- Rambam Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Bernardo Melamud
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; (T.N.); (U.K.); (Y.H.); (R.E.); (A.L.-Z.); (A.H.); (N.M.); (E.I.); (B.U.); (B.A.); (B.M.); (Z.S.); (S.H.O.); (S.B.-H.); (E.B.); (Y.R.); (N.A.C.); (E.S.); (T.E.); (H.R.-M.)
- Department of Gastroenterology and Liver Diseases, Wolfson Medical Center, Holon, Israel
| | - Ori Segol
- Unit of Gastroenterology, Lady Davis Carmel Medical Center, Haifa, Israel;
| | - Zippora Shalem
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; (T.N.); (U.K.); (Y.H.); (R.E.); (A.L.-Z.); (A.H.); (N.M.); (E.I.); (B.U.); (B.A.); (B.M.); (Z.S.); (S.H.O.); (S.B.-H.); (E.B.); (Y.R.); (N.A.C.); (E.S.); (T.E.); (H.R.-M.)
- Gastroenterology and Liver Diseases Institute, Shamir Medical Center, Be’er Ya’akov, Israel
| | - Iris Dotan
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel; (I.A.-B.); (H.B.E.); (I.G.); (J.E.O.); (H.Y.); (I.D.); (Y.S.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; (T.N.); (U.K.); (Y.H.); (R.E.); (A.L.-Z.); (A.H.); (N.M.); (E.I.); (B.U.); (B.A.); (B.M.); (Z.S.); (S.H.O.); (S.B.-H.); (E.B.); (Y.R.); (N.A.C.); (E.S.); (T.E.); (H.R.-M.)
| | - Selwyn H. Odes
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; (T.N.); (U.K.); (Y.H.); (R.E.); (A.L.-Z.); (A.H.); (N.M.); (E.I.); (B.U.); (B.A.); (B.M.); (Z.S.); (S.H.O.); (S.B.-H.); (E.B.); (Y.R.); (N.A.C.); (E.S.); (T.E.); (H.R.-M.)
- Mayanei HaYeshua Medical Center, Bnei Brak, Israel
| | - Shomron Ben-Horin
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; (T.N.); (U.K.); (Y.H.); (R.E.); (A.L.-Z.); (A.H.); (N.M.); (E.I.); (B.U.); (B.A.); (B.M.); (Z.S.); (S.H.O.); (S.B.-H.); (E.B.); (Y.R.); (N.A.C.); (E.S.); (T.E.); (H.R.-M.)
- Department of Gastroenterology, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Yf’at Snir
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel; (I.A.-B.); (H.B.E.); (I.G.); (J.E.O.); (H.Y.); (I.D.); (Y.S.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; (T.N.); (U.K.); (Y.H.); (R.E.); (A.L.-Z.); (A.H.); (N.M.); (E.I.); (B.U.); (B.A.); (B.M.); (Z.S.); (S.H.O.); (S.B.-H.); (E.B.); (Y.R.); (N.A.C.); (E.S.); (T.E.); (H.R.-M.)
| | - Yael Milgrom
- Hadassah Medical Center, Jerusalem, Israel; (Y.M.); (A.Z.)
| | - Efrat Broide
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; (T.N.); (U.K.); (Y.H.); (R.E.); (A.L.-Z.); (A.H.); (N.M.); (E.I.); (B.U.); (B.A.); (B.M.); (Z.S.); (S.H.O.); (S.B.-H.); (E.B.); (Y.R.); (N.A.C.); (E.S.); (T.E.); (H.R.-M.)
- Gastroenterology and Liver Diseases Institute, Shamir Medical Center, Be’er Ya’akov, Israel
| | - Eran Goldin
- Digestive Diseases Institute, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; (B.K.); (A.B.Y.); (E.G.)
| | - Shmuel Delgado
- Assuta Medical Center, Ben-Gurion University, Negev, Be’er Sheva, Israel;
| | - Yulia Ron
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; (T.N.); (U.K.); (Y.H.); (R.E.); (A.L.-Z.); (A.H.); (N.M.); (E.I.); (B.U.); (B.A.); (B.M.); (Z.S.); (S.H.O.); (S.B.-H.); (E.B.); (Y.R.); (N.A.C.); (E.S.); (T.E.); (H.R.-M.)
- Sourasky Medical Center, Tel Aviv, Israel
| | - Nathaniel Aviv Cohen
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; (T.N.); (U.K.); (Y.H.); (R.E.); (A.L.-Z.); (A.H.); (N.M.); (E.I.); (B.U.); (B.A.); (B.M.); (Z.S.); (S.H.O.); (S.B.-H.); (E.B.); (Y.R.); (N.A.C.); (E.S.); (T.E.); (H.R.-M.)
- Sourasky Medical Center, Tel Aviv, Israel
| | - Eran Maoz
- Clalit Health Services, Tel Aviv, Israel; (L.L.); (E.M.); (M.Z.)
| | - Maya Zborovsky
- Clalit Health Services, Tel Aviv, Israel; (L.L.); (E.M.); (M.Z.)
| | | | - Naim Abu Freha
- Soroka Medical Center, Be’er Sheva, Israel; (N.A.F.); (A.S.)
| | - Eyal Shachar
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; (T.N.); (U.K.); (Y.H.); (R.E.); (A.L.-Z.); (A.H.); (N.M.); (E.I.); (B.U.); (B.A.); (B.M.); (Z.S.); (S.H.O.); (S.B.-H.); (E.B.); (Y.R.); (N.A.C.); (E.S.); (T.E.); (H.R.-M.)
- Department of Gastroenterology, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Yehuda Chowers
- Faculty of Medicine, Israel Institute of Technology, Haifa, Israel; (M.W.); (D.B.H.); (Y.C.)
- Rambam Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tal Engel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; (T.N.); (U.K.); (Y.H.); (R.E.); (A.L.-Z.); (A.H.); (N.M.); (E.I.); (B.U.); (B.A.); (B.M.); (Z.S.); (S.H.O.); (S.B.-H.); (E.B.); (Y.R.); (N.A.C.); (E.S.); (T.E.); (H.R.-M.)
- Department of Gastroenterology, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Hila Reiss-Mintz
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; (T.N.); (U.K.); (Y.H.); (R.E.); (A.L.-Z.); (A.H.); (N.M.); (E.I.); (B.U.); (B.A.); (B.M.); (Z.S.); (S.H.O.); (S.B.-H.); (E.B.); (Y.R.); (N.A.C.); (E.S.); (T.E.); (H.R.-M.)
- Mayanei HaYeshua Medical Center, Bnei Brak, Israel
| | - Arie Segal
- Soroka Medical Center, Be’er Sheva, Israel; (N.A.F.); (A.S.)
| | - Adar Zinger
- Hadassah Medical Center, Jerusalem, Israel; (Y.M.); (A.Z.)
| | - Ariella Bar-Gil Shitrit
- Digestive Diseases Institute, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; (B.K.); (A.B.Y.); (E.G.)
- Correspondence:
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11
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Gorelik Y, Freilich S, Gerassy-Vainberg S, Pressman S, Friss C, Blatt A, Focht G, Weisband YL, Greenfeld S, Kariv R, Lederman N, Dotan I, Geva-Zatorsky N, Shen-Orr SS, Kashi Y, Chowers Y. Antibiotic use differentially affects the risk of anti-drug antibody formation during anti-TNFα therapy in inflammatory bowel disease patients: a report from the epi-IIRN. Gut 2022; 71:287-295. [PMID: 34344783 PMCID: PMC8762017 DOI: 10.1136/gutjnl-2021-325185] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 05/16/2021] [Accepted: 07/21/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Anti-drug antibodies (ADA) to anti-tumour necrosis factor (anti-TNF) therapy drive treatment loss of response. An association between intestinal microbial composition and response to anti-TNF therapy was noted. We therefore aimed to assess the implications of antibiotic treatments on ADA formation in patients with inflammatory bowel disease (IBD). DESIGN We analysed data from the epi-IIRN (epidemiology group of the Israeli IBD research nucleus), a nationwide registry of all patients with IBD in Israel. We included all patients treated with anti-TNF who had available ADA levels. Survival analysis with drug use as time varying covariates were used to assess the association between antibiotic use and ADA development. Next, specific pathogen and germ-free C57BL mice were treated with respective antibiotics and challenged with infliximab. ADA were assessed after 14 days. RESULTS Among 1946 eligible patients, with a median follow-up of 651 days from initiation of therapy, 363 had positive ADA. Cox proportional hazard model demonstrated an increased risk of ADA development in patients who used cephalosporins (HR=1.97, 95% CI 1.58 to 2.44), or penicillins with β-lactamase inhibitors (penicillin-BLI, HR=1.4, 95% CI 1.13 to 1.74), whereas a reduced risk was noted in patients treated with macrolides (HR=0.38, 95% CI 0.16 to 0.86) or fluoroquinolones (HR=0.20, 95% CI 0.12 to 0.35). In mice exposed to infliximab, significantly increased ADA production was observed in cephalosporin as compared with macrolide pretreated mice. Germ-free mice produced no ADA. CONCLUSION ADA production is associated with the microbial composition. The risk of ADA development during anti-TNF therapy can possibly be reduced by avoidance of cephalosporins and penicillin-BLIs, or by treatment with fluoroquinolones or macrolides.
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Affiliation(s)
- Yuri Gorelik
- Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Shay Freilich
- Faculty of Biotechnology and Food Engineering, Technion Israel Institute of Technology, Haifa, Israel,Clinical Research Institute, Rambam Health Care Campus, Haifa, Israel
| | - Shiran Gerassy-Vainberg
- Clinical Research Institute, Rambam Health Care Campus, Haifa, Israel,Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Sigal Pressman
- Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Chagit Friss
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, The Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Gili Focht
- The Juliet Keiden Institute of Pediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, Jerusalem, Israel
| | | | - Shira Greenfeld
- Medical Informatics, Maccabi Health Services, Tel Aviv, Israel,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Revital Kariv
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel,Gastroenterology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Nathan Lederman
- Gastroenterology, Meuhedet Health Services, Jerusalem, Israel
| | - Iris Dotan
- Gastroenterology, Rabin Medical Center, Petah Tikva, Israel,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Naama Geva-Zatorsky
- Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel,Rappaport Technion Integrated Cancer Center (RTICC), Technion Israel Institute of Technology, Haifa, Israel
| | | | - Yechezkel Kashi
- Faculty of Biotechnology and Food Engineering, Technion Israel Institute of Technology, Haifa, Israel
| | - Yehuda Chowers
- Gastroenterology, Rambam Health Care Campus, Haifa, Israel
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12
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Ben-Horin S, Novack L, Mao R, Guo J, Zhao Y, Sergienko R, Zhang J, Kobayashi T, Hibi T, Chowers Y, Peyrin-Biroulet L, Colombel JF, Kaplan GG, Chen MH. Efficacy of Biologic Drugs in Short-Duration Versus Long-Duration Inflammatory Bowel Disease: A Systematic Review and an Individual-Patient Data Meta-Analysis of Randomized Controlled Trials. Gastroenterology 2022; 162:482-494. [PMID: 34757139 DOI: 10.1053/j.gastro.2021.10.037] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 09/11/2021] [Accepted: 10/25/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS Starting biologic treatment early in the course of inflammatory bowel disease (IBD) may be associated with higher efficacy, especially in Crohn's disease (CD). METHODS This was a systematic review and individual-patient data meta-analysis of all placebo-controlled trials of biologics approved for IBD at study inception (October 2015), using Vivli data-sharing platform. The primary outcome was the proportional biologic/placebo treatment effect on induction of remission in patients with short-duration (≤18 months) vs long-duration disease (>18 months) analyzed separately for CD and ulcerative colitis (UC). We used meta-regression to examine the impact of patients' characteristics on the primary outcome. RESULTS We included 25 trials, testing infliximab, adalimumab, certolizumab, golimumab, natalizumab, or vedolizumab (6168 patients with CD and 3227 patients with UC). In CD, remission induction rates were higher in pooled placebo and patients in active arms with short-duration disease of ≤18 months (41.4% [244 of 589]) compared with disease duration of >18 months (29.8% [852 of 2857], meta-analytically estimated odds ratio, 1.33; 95% confidence interval, 1.09-1.64). The primary outcome, proportional biologic/placebo treatment effect on induction of remission, was not different in short-duration disease of ≤18 months (n = 589, odds ratio, 1.47; 95% confidence interval, 1.01-2.15) compared with longer disease duration (n = 2857, odds ratio, 1.43; 95% confidence interval, 1.19-1.72). In UC trials, both the proportional biologic/placebo remission-induction effect and the pooled biologic-placebo effect were stable, regardless of disease duration. Primary outcome results remained unchanged when tested using alternative temporal cutoffs and when modeled for individual patient's covariates, including prior anti-tumor necrosis factor exposure. CONCLUSIONS There are higher rates of induction of remission with biologics and with placebo in early CD, resulting in a treatment to placebo effect ratio that is similar across disease durations. No such relationships between disease duration and outcomes was found in UC. PROSPERO registration: CRD42018041961.
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Affiliation(s)
- Shomron Ben-Horin
- Department of Gastroenterology, First Affiliated Hospital of the Sun Yatsen University, Guangzhou, China; Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.
| | - Lena Novack
- Clinical Research Center, Soroka University Medical Center, Beer-Sheva, Israel; Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ren Mao
- Department of Gastroenterology, First Affiliated Hospital of the Sun Yatsen University, Guangzhou, China
| | - Jing Guo
- Department of Gastroenterology, First Affiliated Hospital of the Sun Yatsen University, Guangzhou, China
| | - Yue Zhao
- Department of Gastroenterology, First Affiliated Hospital of the Sun Yatsen University, Guangzhou, China
| | - Ruslan Sergienko
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Jian Zhang
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Taku Kobayashi
- Center for Advanced Inflammatory Bowel Disease Research and Treatment, Kitasato University, Kitasato Institute Hospital, Tokyo, Japan
| | - Toshifumi Hibi
- Center for Advanced Inflammatory Bowel Disease Research and Treatment, Kitasato University, Kitasato Institute Hospital, Tokyo, Japan
| | - Yehuda Chowers
- Department of Gastroenterology, Rambam Health Care Campus, Bruce and Ruth Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel
| | | | - Jean Frederic Colombel
- Helmsley Inflammatory Bowel Disease Center, Icahn School of Medicine, Mount Sinai Hospital, New York, New York
| | - Gilaad G Kaplan
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Canada
| | - Min-Hu Chen
- Department of Gastroenterology, First Affiliated Hospital of the Sun Yatsen University, Guangzhou, China.
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13
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Stulman MY, Asayag N, Focht G, Brufman I, Cahan A, Ledderman N, Matz E, Chowers Y, Eliakim R, Ben-Horin S, Odes S, Dotan I, Balicer RD, Benchimol EI, Turner D. Epidemiology of Inflammatory Bowel Diseases in Israel: A Nationwide Epi-Israeli IBD Research Nucleus Study. Inflamm Bowel Dis 2021; 27:1784-1794. [PMID: 33438721 DOI: 10.1093/ibd/izaa341] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND There are currently no nationwide data on the epidemiology of inflammatory bowel diseases (IBD) in Israel. We aimed to determine the population-based epidemiological trends of IBD in the diverse Israeli population. METHODS Health-administrative data were retrieved from all 4 Israeli health maintenance organizations, insuring 98% of the population, using validated identification algorithms. National trends were determined using Joinpoint regression analysis calculating annual percent change and average annual percent change (AAPC). RESULTS By 2019, there were 46,074 patients with IBD in Israel, corresponding to a national prevalence of 519/100,000 (0.52%), of whom 54.1% had Crohn disease (CD) and 45.9% had ulcerative colitis (UC). The number of Jewish patients doubled from 18,701 in 2005 (354/100,000) to 38,950 (589/100,000) in 2018 (AAPC, +4.0%; P < 0.05), and the number of Arab patients increased 3-fold from 1096 (102.1/100,000) to 3534 (240.7/100,000; AAPC, +6.8%; P < 0.05) during the same years. However, the increase rate has gradually decelerated over time (annual percent change during 2005-2008, 2009-2014, and 2005-2018 was +6.7%, +4.2%, and +2.3%, respectively; P < 0.05). Pediatric prevalence increased from 37.4 to 52.2/100,000, with CD predominating in both Jews and Arabs. The incidence of CD remained stable (from 15.9/100,000 to 14.9/100,000) and the incidence of UC decreased (15.4/100,000 to 10.5/100,000 (AAPC, -3.2%; P < 0.001)). In contrast, pediatric incidence of CD increased from 7.3/100,000 to 8.3/100,000 (AAPC, +1.9%; P < 0.05) and that of UC increased from 2.6 to 4.4/100,000 (AAPC, +5.8%; P < 0.05). CONCLUSIONS The IBD prevalence rate in Israel is still increasing but gradually decelerating, probably due to the decreasing overall IBD incidence. Nonetheless, incidence rate in children is still increasing. Ongoing narrowing in the rates between Jews and Arabs over time may indicate shared environmental factors.
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Affiliation(s)
- Mira Y Stulman
- The Juliet Keiden Institute of Pediatric Gastroenterology and Nutrition Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel.,Braun School of Public and Community Medicine, The Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Noa Asayag
- The Juliet Keiden Institute of Pediatric Gastroenterology and Nutrition Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Gili Focht
- The Juliet Keiden Institute of Pediatric Gastroenterology and Nutrition Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ilan Brufman
- Clalit Research Institute, Chief's Office, Clalit Health Services, Tel Aviv, Israel
| | - Amos Cahan
- Maccabi Healthcare Services, Tel Aviv, Israel
| | | | - Eran Matz
- Leumit Health Services, Tel Aviv, Israel
| | - Yehuda Chowers
- Department of Gastroenterology, Rambam Healthcare Campus, Bruce Rappaport School of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Rami Eliakim
- Department of Gastroenterology, Chaim Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shomron Ben-Horin
- Department of Gastroenterology, Chaim Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shmuel Odes
- Department of Gastroenterology and Hepatology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Iris Dotan
- Division of Gastroenterology, Rabin Medical Center, Petah Tivka, and the Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Ran D Balicer
- Clalit Research Institute, Chief's Office, Clalit Health Services, Tel Aviv, Israel
| | - Eric I Benchimol
- Department of Pediatrics and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.,CHEO Inflammatory Bowel Disease Centre and CHEO Research Institute, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Dan Turner
- The Juliet Keiden Institute of Pediatric Gastroenterology and Nutrition Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
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14
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Ungar B, Malickova K, Hanžel J, Abu Arisha M, Paul S, Rocha C, Ben Shatach Z, Abitbol CM, Haj Natour O, Selinger L, Yavzori M, Fudim E, Picard O, Shoval I, Eliakim R, Kopylov U, Magro F, Roblin X, Chowers Y, Drobne D, Lukas M, Ben Horin S. Dose optimisation for Loss of Response to Vedolizumab- Pharmacokinetics and Immune Mechanisms. J Crohns Colitis 2021; 15:1707-1719. [PMID: 33837762 DOI: 10.1093/ecco-jcc/jjab067] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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] [Indexed: 12/13/2022]
Abstract
BACKGROUND Real life data regarding pharmacokinetics of vedolizumab in patients needing dose optimisation are scarce. We set to examine whether pre-optimisation vedolizumab levels associate with therapy outcomes and which mechanisms explain the associations. METHODS A multicentre observational study assessed the outcome of dose increase in association with pre-escalation levels in vedolizumab-treated patients. SubsequentIy, α4β7 occupancy on peripheral blood [PB] and intestinal lamina propria [LP] tissues was investigated on various cellular subsets in patients undergoing lower endoscopy on infusion day. Cellular localisation of vedolizumab-bound α4β7 and effects on M1 and M2 macrophages were also explored. RESULTS A total of 161 inflammatory bowel disease [IBD] patients were included. Among 129/161 patients intensified during maintenance [Week 14 onward], pre-intensification trough levels were comparable or higher among those subsequently attaining post-optimisation clinical, biomarker, and endoscopic remission, compared with non-remitting patients [p = 0.09, 0.25, 0.04, respectively]. Similar results were demonstrated for those dose-optimised during induction [Week 6, n = 32]. In the immune sub-study [n = 43], free α4β7 receptors at trough were similarly low among patients with/without mucosal healing, on PB T cells [p = 0.15], LP T cells [p = 0.88], and on PB eosinophils [p = 0.08]. Integrin receptors on M1 and M2 macrophages were also saturated by low levels of vedolizumab and anti-inflammatory cytokine secretion was not increased. Co-localisation and dissociation experiments demonstrated membranal α4β7 receptors of two origins: non-internalised and newly generated α4β7, but re-binding was still complete at very low concentrations. CONCLUSIONS These results do not support pharmacokinetics as the mechanism responsible for loss of response to vedolizumab, nor do they support a need for higher drug concentration to enhance vedolizumab's immune effects. Higher pre-escalation levels may indicate less clearance [less severe disease] and higher likelihood of subsequent re-gained response, regardless of therapy escalation.
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Affiliation(s)
- Bella Ungar
- Gastroenterology Institute, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Karin Malickova
- IBD Clinical and Research Centre, ISCARE, Prague, Czech Republic
| | - Jurij Hanžel
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljuljana, Slovenia
| | - Muhammad Abu Arisha
- Rambam Health Care Campus, Bruce and Ruth Rappaport Faculty of Medicine, Haifa, Israel
| | - Stephane Paul
- Immunology Department, GIMAP CIC INSERM 1408, University of Lyon, Saint Etienne, France
| | - Catia Rocha
- Department of Biomedicine, Unit of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal.,Instituto de Saúde Ambiental, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Zohar Ben Shatach
- Gastroenterology Institute, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Chaya Mushka Abitbol
- Gastroenterology Institute, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ola Haj Natour
- Gastroenterology Institute, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Limor Selinger
- Gastroenterology Institute, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Miri Yavzori
- Gastroenterology Institute, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ella Fudim
- Gastroenterology Institute, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orit Picard
- Gastroenterology Institute, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Irit Shoval
- Mina and Everard Goodman Faculty of Life Sciences, Bar Ilan, Ramat Gan, Israel
| | - Rami Eliakim
- Gastroenterology Institute, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Kopylov
- Gastroenterology Institute, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Fernando Magro
- Department of Biomedicine, Unit of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Xavier Roblin
- Department of Hepatogastroenterology, University Hospital of Saint Etienne, Saint Etienne, France
| | - Yehuda Chowers
- Rambam Health Care Campus, Bruce and Ruth Rappaport Faculty of Medicine, Haifa, Israel
| | - David Drobne
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljuljana, Slovenia.,Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Milan Lukas
- IBD Clinical and Research Centre, ISCARE, Prague, Czech Republic
| | - Shomron Ben Horin
- Gastroenterology Institute, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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15
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Gorelik Y, Hag E, Hananya T, Leiba R, Chowers Y, Half EE. Volume of fluid consumption during preparation for colonoscopy is possibly the single most important determinant of bowel preparation adequacy. Ann Gastroenterol 2021; 34:705-712. [PMID: 34475742 PMCID: PMC8375653 DOI: 10.20524/aog.2021.0642] [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: 10/25/2020] [Accepted: 12/29/2020] [Indexed: 12/05/2022] Open
Abstract
Background The effectiveness and safety of colonoscopy are directly dependent on the quality of bowel preparation. Multiple risk factors for inadequate bowel preparation (IBP) have been identified; however, IBP is still reported in 20-30% of cases in most studies. We aimed to identify modifiable predictors of the adequacy of bowel preparation using sodium picosulfate, and to recommend easily modifiable parameters to increase the success rate of colonoscopies. Methods This was a single-center observational study of adult outpatients referred for an elective colonoscopy. Patients were interviewed prior to colonoscopy; volume of liquids consumed was calculated as number of 200-mL cups showed to the patient. Additional information, including medical history, diagnoses and regular medications, was procured from patients’ medical records. Univariate and multivariate regression analyses were performed to identify factors significantly associated with IBP in a subgroup analysis of high-risk patients. Results The rate of IBP in 1172 subjects was 19.4%. This rate decreased as fluid consumption increased, with a further drop associated with shorter intervals from end of preparation to colonoscopy. Drinking < 1.4 L significantly increased the risk of IBP (odds ratio [OR] 3.62, 95% confidence interval [CI] 2.65-4.95), while drinking ≥2 L was associated with adequate preparation (OR 0.09, 95%CI 0-0.42). These associations were stronger in high-risk individuals. Conclusion Greater fluid intake and short interval to colonoscopy are easily modifiable parameters that can substantially reduce the rate of IBP, especially among high-risk individuals.
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Affiliation(s)
- Yuri Gorelik
- Department of Internal Medicine D, Rambam Health Care Campus (Yuri Gorelik)
| | - Eisa Hag
- Gastroenterology Institute, Rambam Health Care Campus (Eisa Hag, Yehuda Chowers, Elizabeth E. Half)
| | - Tomer Hananya
- Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology (Tomer Hananya, Yehuda Chowers, Elizabeth E. Half)
| | - Ronit Leiba
- Department of Epidemiology, Rambam Health Care Campus (Ronit Leiba), Haifa, Israel
| | - Yehuda Chowers
- Gastroenterology Institute, Rambam Health Care Campus (Eisa Hag, Yehuda Chowers, Elizabeth E. Half).,Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology (Tomer Hananya, Yehuda Chowers, Elizabeth E. Half)
| | - Elizabeth E Half
- Gastroenterology Institute, Rambam Health Care Campus (Eisa Hag, Yehuda Chowers, Elizabeth E. Half).,Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology (Tomer Hananya, Yehuda Chowers, Elizabeth E. Half)
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16
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Yanai H, Goren I, Godny L, Maharshak N, Ron Y, Avni Biron I, Leibovitzh H, Banai Eran H, Aharoni Golan M, Rabinowitz K, Ziv Baran T, Lavie I, Yadgar K, Zonensain K, Kopylov U, Ben Horin S, Eliakim R, Waterman M, Chowers Y, Ben-Shachar S, Dotan I. Early Indolent Course of Crohn's Disease in Newly Diagnosed Patients Is Not Rare and Possibly Predictable. Clin Gastroenterol Hepatol 2021; 19:1564-1572.e5. [PMID: 32629126 DOI: 10.1016/j.cgh.2020.06.069] [Citation(s) in RCA: 4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 05/28/2020] [Accepted: 06/23/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The early stages of Crohn's disease (CD) course are heterogeneous, and it is a challenge to predict the course of disease in patients with new diagnosis. METHODS We performed an observational longitudinal study of 156 adults (79 male; median age, 27.7 years; 57 treatment naïve) with newly diagnosed CD (within 6 months of enrollment), referred from medical centers and community clinics in Israel from 2013 through 2017. Study participants each received semi-annual scheduled evaluations. Indolent disease was defined as a disease course without need for strict interventions to control complicated course of CD (hospitalization or surgery, or decision to start steroid, immunomodulator, or biologic therapy). Cox regression and receiver operating characteristic analyses were used to identify factors associated with early indolent or complicated course of CD. We validated our findings in an independent cohort of patients with CD from a separate medical center in Israel in 2018. RESULTS Over a median follow-up period of 17.2 months (interquartile range, 8.8-23.8 months), 52 patients (33.3%) had an indolent course of CD, 29 (18.5%) required hospitalizations, and 75 (48%) were recommended to start steroid, immunomodulator, or biologic therapies. The median time to first intervention was 3.4 months (95% CI, 2.4-4.4). We developed a model based on clinical factors that identified 4 factors associated with complicated course in treatment-naïve patients: body mass index <25 kg/m2 (hazard ratio [HR], 2.45; 95% CI, 1.07-5.43; P = .033), serum level of vitamin B12 <350 pg/mL (HR, 2.78; 95% CI, 1.21-6.41; P = .016), white blood cells ≥7 × 103/μL (HR, 2.419; 95% CI, 1.026-5.703; P = .044), and serum level of ALT ≥25 IU/L (HR, 2.680; 95% CI, 1.186-6.058; P = .018). This model discriminated between patients with vs without a complicated course of disease with 90% and 89% accuracy at 6 and 12 months after diagnosis, respectively. A validation cohort demonstrated a discriminatory ability of 79% at 3 months after diagnosis, and a nomogram was constructed. CONCLUSIONS In an observational longitudinal study of 156 patients with newly diagnosed CD, we found that one third have an early indolent course of disease. We identified factors that can be measured at diagnosis to identify patients at risk for an early complicated course-these might be used in patient management and selection of treatment.
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Affiliation(s)
- Henit Yanai
- IBD Center, Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Idan Goren
- IBD Center, Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lihi Godny
- IBD Center, Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nitsan Maharshak
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; IBD Center, Department of Gastroenterology and Liver Diseases, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yulia Ron
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; IBD Center, Department of Gastroenterology and Liver Diseases, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Irit Avni Biron
- IBD Center, Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Haim Leibovitzh
- IBD Center, Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hagar Banai Eran
- IBD Center, Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Maya Aharoni Golan
- IBD Center, Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Keren Rabinowitz
- IBD Center, Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tomer Ziv Baran
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Epidemiology and Preventive Medicine, School of Public Health, Tel Aviv University, Tel Aviv, Israel
| | - Inbar Lavie
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Karin Yadgar
- IBD Center, Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel
| | - Keren Zonensain
- IBD Center, Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel
| | - Uri Kopylov
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Gastroenterology, Sheba Medical Center, Ramat Gan, Israel
| | - Shomron Ben Horin
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Gastroenterology, Sheba Medical Center, Ramat Gan, Israel; Sun Yat-Sen University, Guangzhou, China
| | - Rami Eliakim
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Gastroenterology, Sheba Medical Center, Ramat Gan, Israel
| | - Matti Waterman
- Department of Gastroenterology, Rambam Health Care Campus and Bruce Rappaport School of Medicine, Technion Institute of Technology, Haifa, Israel
| | - Yehuda Chowers
- Department of Gastroenterology, Rambam Health Care Campus and Bruce Rappaport School of Medicine, Technion Institute of Technology, Haifa, Israel
| | - Shay Ben-Shachar
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Clalit Research Institute, Ramat-Gan, Israel
| | - Iris Dotan
- IBD Center, Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Bar-Yoseph H, Carasso S, Shklar S, Korytny A, Even Dar R, Daoud H, Nassar R, Maharshak N, Hussein K, Geffen Y, Chowers Y, Geva-Zatorsky N, Paul M. Oral Capsulized Fecal Microbiota Transplantation for Eradication of Carbapenemase-producing Enterobacteriaceae Colonization With a Metagenomic Perspective. Clin Infect Dis 2021; 73:e166-e175. [PMID: 32511695 DOI: 10.1093/cid/ciaa737] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [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: 02/13/2020] [Accepted: 06/04/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Carbapenemase-producing Enterobacteriaceae (CPE) infections lead to considerable morbidity and mortality. We assessed the potential of fecal microbiota transplantation (FMT) to eradicate CPE carriage and aimed to explain failure or success through microbiome analyses. METHODS In this prospective cohort study, all consenting eligible CPE carriers received oral capsulized FMT for 2 days. Primary outcome was CPE eradication at 1 month, defined by 3 consecutive negative rectal swabs, the last also negative for carbapenemase gene by polymerase chain reaction. Comprehensive metagenomics analysis of the intestinal microbiome of donors and recipients before and after FMT was performed. RESULTS Fifteen CPE carriers received FMT, 13 of whom completed 2 days of treatment. CPE eradication at 1 month was successful in 9/15 and 9/13, respectively. Bacterial communities showed significant changes in both beta and alpha diversity metrics among participants who achieved CPE eradication that were not observed among failures. Post-FMT samples' beta-diversity clustered according to the treatment outcome, both in taxonomy and in function. We observed a significant decrease in beta diversity in participants who received post-FMT antibiotics. Enterobacteriaceae abundance decreased in post-FMT samples of the responders but increased among failures. Functionally, a clear demarcation between responders (who were similar to the donors) and failures was shown, driven by antimicrobial resistance genes. CONCLUSIONS Our study provides the biological explanation for the effect of FMT against CPE carriage. Decolonization of CPE by FMT is likely mediated by compositional and functional shifts in the microbiome. Thus, FMT might be an efficient strategy for sustained CPE eradication. CLINICAL TRIALS REGISTRATION NCT03167398.
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Affiliation(s)
- Haggai Bar-Yoseph
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel.,Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Shaqed Carasso
- Department of Cell Biology and Cancer Science, Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Technion Integrated Cancer Center, Haifa, Israel
| | - Shlomit Shklar
- Division of Infectious Disease, Rambam Health Care Campus, Haifa, Israel
| | - Alexander Korytny
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Razi Even Dar
- Department of Internal Medicine H, Rambam Health Care Campus, Haifa, Israel
| | - Haneen Daoud
- Department of Internal Medicine H, Rambam Health Care Campus, Haifa, Israel
| | - Roni Nassar
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Nitsan Maharshak
- Bacteriotherapy Clinic, Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel (affiliated with the Sackler Faculty of Medicine, Tel Aviv University)
| | - Khetam Hussein
- Division of Infectious Disease, Rambam Health Care Campus, Haifa, Israel
| | - Yuval Geffen
- Microbiology Laboratory, Rambam Health Care Campus, Haifa, Israel
| | - Yehuda Chowers
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel.,Clinical Research Institute, Rambam Health Care Campus, Haifa, Israel
| | - Naama Geva-Zatorsky
- Department of Cell Biology and Cancer Science, Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Technion Integrated Cancer Center, Haifa, Israel.,Canadian Institute for Advanced Research, MaRS Centre, Toronto, Ontario, Canada
| | - Mical Paul
- Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel.,Division of Infectious Disease, Rambam Health Care Campus, Haifa, Israel
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18
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Weisshof R, Chowers Y, Kurnik D. Editorial: safety of thiopurines in pregnancy-considering the mother, foetus and newborn. Aliment Pharmacol Ther 2021; 54:88-89. [PMID: 34109665 DOI: 10.1111/apt.16342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Roni Weisshof
- Department of Gastroenterology, Rambam Healthcare Campus, Haifa, Israel
| | - Yehuda Chowers
- Department of Gastroenterology, Rambam Healthcare Campus, Haifa, Israel.,Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Daniel Kurnik
- Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.,Section of Clinical Pharmacology and Toxicology, Rambam Healthcare Campus, Haifa, Israel
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19
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Lambrescak E, Vaysse T, Allez M, Ungar B, Gleizes A, Hacein-Bey S, Chowers Y, Roblin X, Kopylov U, Rachas A, Carbonnel F. Duration of combination therapy and risk of treatment failure in patients with inflammatory bowel disease. Clin Res Hepatol Gastroenterol 2021; 45:101503. [PMID: 32893176 DOI: 10.1016/j.clinre.2020.07.008] [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: 08/29/2019] [Revised: 06/02/2020] [Accepted: 07/10/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Patients who receive infliximab (IFX) combined with a thiopurine, for inflammatory bowel disease, have a better clinical response and less frequent immunization towards IFX than those treated with IFX alone. The benefits of combination therapy must be weighed against the risks of infection and cancer. We studied the association between the duration of combination therapy and the risk of treatment failure by two year from initiation. METHODS Participants had Crohn's disease or ulcerative colitis and were in clinical and biological remission, 6 months after initiation of combination therapy. The risk of subsequent treatment failure (i.e., undetectable trough IFX levels and/or clinical relapse followed by surgical treatment or switch of maintenance treatment) was estimated using Kaplan-Meier method and adjusted Hazard Ratios (aHRs), in patients whohadreceived 6 to 11 months vs. 12 months or more of combination therapy. We performed a similar analysis in which the follow-up was started at discontinuation of the immunosuppressant. RESULTS Among 139 patients (48% women; median age 31.1), with a median follow-up of 18.9 months, we observed 26 treatment failures (including 15 patients with undetectable trough IFX levels). After adjustment for gender and type of immunomodulator, a shorter duration of combination therapy was not associated with a higher risk of treatment failure (aHR=0.42; 95% confidence interval (95%CI): 0.13-1.40; p=0.16). When the follow-up was started at discontinuation of the immunosuppressant, a combination therapy of 6-11 months was associated with a numerically lower risk of treatment failure as compared with a longer combination therapy (HR=0.12; 95%CI: 0.01-1.05; p=0.055). CONCLUSION Our results do not show any benefit for continuation of combination therapy for more than 12 months after achieving clinical remission in IBD patients.
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Affiliation(s)
- Elsa Lambrescak
- Hôpital du Kremlin-Bicêtre, Service de Gastroentérologie, APHP, Université Paris Sud, 78 rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - Thibaut Vaysse
- Hôpital du Kremlin-Bicêtre, Service de Gastroentérologie, APHP, Université Paris Sud, 78 rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - Matthieu Allez
- Hôpital Saint Louis, Service de Gastroentérologie, APHP, Université Denis Diderot, 1 Avenue Claude, Vellefaux 75010, France
| | - Bella Ungar
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Ramat Gan, affiliated to Sackler Medical School, Tel Aviv University, Israel
| | - Aude Gleizes
- Hôpital du Kremlin-Bicêtre, Laboratoire d'immunologie, APHP, Université Paris Sud, 78 rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - Salima Hacein-Bey
- Hôpital du Kremlin-Bicêtre, Laboratoire d'immunologie, APHP, Université Paris Sud, 78 rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - Yehuda Chowers
- Gastroenterology Institute, Rambam Rambam Health Care Campus, Haifa, Israel
| | - Xavier Roblin
- CHU de Saint-Etienne, Hôpital Bellevue, Service d'hépato-gastro-entérologie, 25 Boulevard Pasteur, 42055 Saint-Etienne Cedex 2, France
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Ramat Gan, affiliated to Sackler Medical School, Tel Aviv University, Israel
| | - Antoine Rachas
- Hôpital du Kremlin-Bicêtre, Service de Santé Publique, APHP, Université Paris Sud, 78 rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - Franck Carbonnel
- Hôpital du Kremlin-Bicêtre, Service de Gastroentérologie, APHP, Université Paris Sud, 78 rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France
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20
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Ng SC, Mak JWY, Hitz L, Chowers Y, Bernstein CN, Silverberg MS. COVID-19 Pandemic: Which IBD Patients Need to Be Scoped-Who Gets Scoped Now, Who Can Wait, and how to Resume to Normal. J Crohns Colitis 2020; 14:S791-S797. [PMID: 33085973 PMCID: PMC7665406 DOI: 10.1093/ecco-jcc/jjaa128] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Endoscopy is an essential component in the management of inflammatory bowel disease [IBD]. There is a risk of SARS-CoV-2 transmission during endoscopic procedures. The International Organization for the study of IBD [IOIBD] has developed 11 position statements, based on an online survey, that focus on how to prioritise endoscopies in IBD patients during the COVID-19 pandemic, alternative modes for disease monitoring, and ways to triage the high number of postponed endoscopies after the pandemic. We propose to pre-screen patients for suspected or confirmed COVID-19 and test for SARS-CoV-2 before endoscopy if available. High priority endoscopies during pandemic include acute gastrointestinal bleed, acute severe ulcerative colitis, new IBD diagnosis, cholangitis in primary sclerosing cholangitis, and partial bowel obstruction. Alternative modes of monitoring using clinical symptoms, serum inflammatory markers, and faecal calprotectin should be considered during the pandemic. Prioritising access to endoscopy in the post-pandemic period should be guided by control of COVID-19 in the local community and availability of manpower and personal protective equipment. Endoscopy should be considered within 3 months after the pandemic for patients with a past history of dysplasia and endoscopic resection for dysplastic lesion. Endoscopy should be considered 3-6 months after the pandemic for assessment of postoperative recurrence or new biologic initiation. Endoscopy can be postponed until after 6 months of pandemic for routine IBD surveillance and assessment of mucosal healing.
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Affiliation(s)
- Siew C Ng
- aInstitute of Digestive Disease, Department of Medicine and Therapeutics, LKS Institute of Health Science, Chinese University of Hong Kong, Hong Kong,Corresponding author: Siew C. Ng, MBBS (Lond) PhD (Lond) FRCP (Lond) FRCP (Edin) AGAF FHKCP FHKAM (Med), Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong; Tel.: +852 3505 3996; fax: +852 2637 3852;
| | - Joyce Wing Yan Mak
- aInstitute of Digestive Disease, Department of Medicine and Therapeutics, LKS Institute of Health Science, Chinese University of Hong Kong, Hong Kong
| | - Lara Hitz
- bMount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Yehuda Chowers
- cDepartment of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
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21
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Hässler S, Bachelet D, Duhaze J, Szely N, Gleizes A, Hacein-Bey Abina S, Aktas O, Auer M, Avouac J, Birchler M, Bouhnik Y, Brocq O, Buck-Martin D, Cadiot G, Carbonnel F, Chowers Y, Comabella M, Derfuss T, De Vries N, Donnellan N, Doukani A, Guger M, Hartung HP, Kubala Havrdova E, Hemmer B, Huizinga T, Ingenhoven K, Hyldgaard-Jensen PE, Jury EC, Khalil M, Kieseier B, Laurén A, Lindberg R, Loercher A, Maggi E, Manson J, Mauri C, Mohand Oumoussa B, Montalban X, Nachury M, Nytrova P, Richez C, Ryner M, Sellebjerg F, Sievers C, Sikkema D, Soubrier M, Tourdot S, Trang C, Vultaggio A, Warnke C, Spindeldreher S, Dönnes P, Hickling TP, Hincelin Mery A, Allez M, Deisenhammer F, Fogdell-Hahn A, Mariette X, Pallardy M, Broët P. Clinicogenomic factors of biotherapy immunogenicity in autoimmune disease: A prospective multicohort study of the ABIRISK consortium. PLoS Med 2020; 17:e1003348. [PMID: 33125391 PMCID: PMC7598520 DOI: 10.1371/journal.pmed.1003348] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 09/18/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Biopharmaceutical products (BPs) are widely used to treat autoimmune diseases, but immunogenicity limits their efficacy for an important proportion of patients. Our knowledge of patient-related factors influencing the occurrence of antidrug antibodies (ADAs) is still limited. METHODS AND FINDINGS The European consortium ABIRISK (Anti-Biopharmaceutical Immunization: prediction and analysis of clinical relevance to minimize the RISK) conducted a clinical and genomic multicohort prospective study of 560 patients with multiple sclerosis (MS, n = 147), rheumatoid arthritis (RA, n = 229), Crohn's disease (n = 148), or ulcerative colitis (n = 36) treated with 8 different biopharmaceuticals (etanercept, n = 84; infliximab, n = 101; adalimumab, n = 153; interferon [IFN]-beta-1a intramuscularly [IM], n = 38; IFN-beta-1a subcutaneously [SC], n = 68; IFN-beta-1b SC, n = 41; rituximab, n = 31; tocilizumab, n = 44) and followed during the first 12 months of therapy for time to ADA development. From the bioclinical data collected, we explored the relationships between patient-related factors and the occurrence of ADAs. Both baseline and time-dependent factors such as concomitant medications were analyzed using Cox proportional hazard regression models. Mean age and disease duration were 35.1 and 0.85 years, respectively, for MS; 54.2 and 3.17 years for RA; and 36.9 and 3.69 years for inflammatory bowel diseases (IBDs). In a multivariate Cox regression model including each of the clinical and genetic factors mentioned hereafter, among the clinical factors, immunosuppressants (adjusted hazard ratio [aHR] = 0.408 [95% confidence interval (CI) 0.253-0.657], p < 0.001) and antibiotics (aHR = 0.121 [0.0437-0.333], p < 0.0001) were independently negatively associated with time to ADA development, whereas infections during the study (aHR = 2.757 [1.616-4.704], p < 0.001) and tobacco smoking (aHR = 2.150 [1.319-3.503], p < 0.01) were positively associated. 351,824 Single-Nucleotide Polymorphisms (SNPs) and 38 imputed Human Leukocyte Antigen (HLA) alleles were analyzed through a genome-wide association study. We found that the HLA-DQA1*05 allele significantly increased the rate of immunogenicity (aHR = 3.9 [1.923-5.976], p < 0.0001 for the homozygotes). Among the 6 genetic variants selected at a 20% false discovery rate (FDR) threshold, the minor allele of rs10508884, which is situated in an intron of the CXCL12 gene, increased the rate of immunogenicity (aHR = 3.804 [2.139-6.764], p < 1 × 10-5 for patients homozygous for the minor allele) and was chosen for validation through a CXCL12 protein enzyme-linked immunosorbent assay (ELISA) on patient serum at baseline before therapy start. CXCL12 protein levels were higher for patients homozygous for the minor allele carrying higher ADA risk (mean: 2,693 pg/ml) than for the other genotypes (mean: 2,317 pg/ml; p = 0.014), and patients with CXCL12 levels above the median in serum were more prone to develop ADAs (aHR = 2.329 [1.106-4.90], p = 0.026). A limitation of the study is the lack of replication; therefore, other studies are required to confirm our findings. CONCLUSION In our study, we found that immunosuppressants and antibiotics were associated with decreased risk of ADA development, whereas tobacco smoking and infections during the study were associated with increased risk. We found that the HLA-DQA1*05 allele was associated with an increased rate of immunogenicity. Moreover, our results suggest a relationship between CXCL12 production and ADA development independent of the disease, which is consistent with its known function in affinity maturation of antibodies and plasma cell survival. Our findings may help physicians in the management of patients receiving biotherapies.
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Affiliation(s)
- Signe Hässler
- CESP, INSERM UMR 1018, Faculty of Medicine, Paris-Sud University, UVSQ, Paris-Saclay University, Villejuif, France
- Sorbonne Université, INSERM UMR 959, Immunology-Immunopathology-Immunotherapy (i3), Paris, France
- AP-HP, Hôpital Pitié-Salpêtrière, Biotherapy (CIC-BTi), Paris, France
- * E-mail: (SH); (PB)
| | - Delphine Bachelet
- CESP, INSERM UMR 1018, Faculty of Medicine, Paris-Sud University, UVSQ, Paris-Saclay University, Villejuif, France
- Department of Biostatistical Epidemiology and Clinical Research, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris AP-HP.Nord, INSERM CIC-EC 1425, Paris, France
| | - Julianne Duhaze
- CESP, INSERM UMR 1018, Faculty of Medicine, Paris-Sud University, UVSQ, Paris-Saclay University, Villejuif, France
- CHU Ste-Justine Research Center, Montreal, Canada
| | - Natacha Szely
- INSERM UMR 996, Faculty of Pharmacy, Paris-Sud University, Paris-Saclay University, Châtenay-Malabry, France
| | - Aude Gleizes
- INSERM UMR 996, Faculty of Pharmacy, Paris-Sud University, Paris-Saclay University, Châtenay-Malabry, France
- Clinical Immunology Laboratory, AP-HP, Le Kremlin-Bicêtre Hospital, Paris-Sud University Hospitals, Le Kremlin-Bicêtre, France
| | - Salima Hacein-Bey Abina
- Clinical Immunology Laboratory, AP-HP, Le Kremlin-Bicêtre Hospital, Paris-Sud University Hospitals, Le Kremlin-Bicêtre, France
- UTCBS, CNRS UMR 8258, INSERM U1022, Faculty of Pharmacy, Paris-Descartes-Sorbonne-Cite University, Paris, France
| | - Orhan Aktas
- University of Düsseldorf, Medical Faculty, Department of Neurology, Düsseldorf, Germany
| | - Michael Auer
- Innsbruck Medical University, Department of Neurology, Innsbruck, Austria
| | - Jerôme Avouac
- Paris University, Paris Descartes University, INSERM U1016, Paris, France
- Rheumatology department, Cochin Hospital, AP-HP.CUP, Paris, France
| | - Mary Birchler
- GlaxoSmithKline, Clinical Immunology–Biopharm, Collegeville, Pennsylvania, United States of America
| | - Yoram Bouhnik
- AP-HP, Hôpital Beaujon, Paris, France
- GETAID, Paris, France
| | | | | | - Guillaume Cadiot
- GETAID, Paris, France
- Service d'hépato-gastroentérologie, University Hospital of Reims, Reims, France
| | - Franck Carbonnel
- GETAID, Paris, France
- Department of Gastroenterology, AP-HP, Hôpital Kremlin-Bicêtre, France
| | - Yehuda Chowers
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel; Bruce Rappaport School of Medicine, Technion Israel Institute of Technology, Haifa, Israel; Clinical Research Institute, Rambam Health Care Campus, Haifa, Israel
| | - Manuel Comabella
- Servei de Neurologia-Neuroimmunologia, Centre d’Esclerosi Múltiple de Catalunya (Cemcat). Institut de Recerca Vall d’Hebron (VHIR). Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Tobias Derfuss
- Departments of Biomedicine and Neurology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Niek De Vries
- Rheumatology & Clinical Immunology, Amsterdam UMC | AMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Abiba Doukani
- Sorbonne Université, Inserm, UMS Production et Analyse des données en Sciences de la vie et en Santé, UMS 37 PASS, Plateforme Post-génomique de la Pitié-Salpêtrière, P3S, Paris, France
| | - Michael Guger
- Clinic for Neurology 2, Med Campus III, Kepler University Hospital GmbH, Linz, Austria
| | - Hans-Peter Hartung
- University of Düsseldorf, Medical Faculty, Department of Neurology, Düsseldorf, Germany
| | - Eva Kubala Havrdova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Bernhard Hemmer
- Department of Neurology, Technische Universität München, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Tom Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Kathleen Ingenhoven
- University of Düsseldorf, Medical Faculty, Department of Neurology, Düsseldorf, Germany
| | - Poul Erik Hyldgaard-Jensen
- Danish Multiple Sclerosis Center, Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Elizabeth C. Jury
- Centre for Rheumatology Research, University College London, London, United Kingdom
| | - Michael Khalil
- Department of Neurology, Medical University of Graz, Austria
| | - Bernd Kieseier
- University of Düsseldorf, Medical Faculty, Department of Neurology, Düsseldorf, Germany
| | | | - Raija Lindberg
- Departments of Biomedicine and Neurology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Amy Loercher
- GlaxoSmithKline, Clinical Immunology–Biopharm, Collegeville, Pennsylvania, United States of America
| | - Enrico Maggi
- Dipartimento di Medicina Sperimentale e Clínica, Università di Firenze, Firenze, Italy
- Immunology Area of Bambino Gesù Pediatric Hospital, IRCCS, Rome, Italy
| | - Jessica Manson
- Department of Rheumatology, University College London Hospital, London, United Kingdom
| | - Claudia Mauri
- Centre for Rheumatology Research, University College London, London, United Kingdom
| | - Badreddine Mohand Oumoussa
- Sorbonne Université, Inserm, UMS Production et Analyse des données en Sciences de la vie et en Santé, UMS 37 PASS, Plateforme Post-génomique de la Pitié-Salpêtrière, P3S, Paris, France
| | - Xavier Montalban
- Servei de Neurologia-Neuroimmunologia, Centre d’Esclerosi Múltiple de Catalunya (Cemcat). Institut de Recerca Vall d’Hebron (VHIR). Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
- Center for Multiple Sclerosis, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Maria Nachury
- GETAID, Paris, France
- University hospital of Lille, Maladies de l'appareil digestif, Lille, France
| | - Petra Nytrova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Christophe Richez
- Rheumatology Department, CHU de Bordeaux-GH Pellegrin, Bordeaux, France
- UMR CNRS 5164, Bordeaux University, Bordeaux, France
| | - Malin Ryner
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Finn Sellebjerg
- Danish Multiple Sclerosis Center, Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Claudia Sievers
- Departments of Biomedicine and Neurology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Dan Sikkema
- GlaxoSmithKline, Clinical Immunology–Biopharm, Collegeville, Pennsylvania, United States of America
- Current address: Quanterix Corporation, Billerica, Massachusetts, United States of America
| | - Martin Soubrier
- Rheumatology, University Hospital of Clermont Ferrand, Clermont Ferrand, France
| | - Sophie Tourdot
- INSERM UMR 996, Faculty of Pharmacy, Paris-Sud University, Paris-Saclay University, Châtenay-Malabry, France
| | - Caroline Trang
- GETAID, Paris, France
- Institut des maladies de l'Appareil Digestif, University Hospital of Nantes, Nantes, France
| | - Alessandra Vultaggio
- Dipartimento di Medicina Sperimentale e Clínica, Università di Firenze, Firenze, Italy
| | - Clemens Warnke
- University of Düsseldorf, Medical Faculty, Department of Neurology, Düsseldorf, Germany
- Department of Neurology, University Hospital Köln, Köln, Germany
| | - Sebastian Spindeldreher
- Drug Metabolism Pharmacokinetics-Biologics, Novartis Institutes for Biomedical Research, Basel, Switzerland
- Integrated Biologix GmbH, Basel, Switzerland
| | | | - Timothy P. Hickling
- BioMedicine Design, Pfizer, Inc., Andover, Massachusetts, United States of America
| | | | - Matthieu Allez
- GETAID, Paris, France
- Department of Gastroenterology, Hôpital Saint-Louis, AP-HP, Université Paris-Diderot, Paris, France
| | | | - Anna Fogdell-Hahn
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Xavier Mariette
- Centre for Immunology of Viral Infections and Autoimmune Diseases, INSERM UMR 1184, Université Paris-Saclay, AP-HP.Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Marc Pallardy
- INSERM UMR 996, Faculty of Pharmacy, Paris-Sud University, Paris-Saclay University, Châtenay-Malabry, France
| | - Philippe Broët
- CESP, INSERM UMR 1018, Faculty of Medicine, Paris-Sud University, UVSQ, Paris-Saclay University, Villejuif, France
- CHU Ste-Justine Research Center, Montreal, Canada
- AP-HP, Paris-Sud University Hospitals, Paul Brousse Hospital, Villejuif, France
- * E-mail: (SH); (PB)
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22
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Levhar N, Ungar B, Kopylov U, Fudim E, Yavzori M, Picard O, Amariglio N, Chowers Y, Shemer-Avni Y, Mao R, Chen MH, Ye Z, Eliakim R, Ben-Horin S. Propagation of EBV-driven Lymphomatous Transformation of Peripheral Blood B Cells by Immunomodulators and Biologics Used in the Treatment of Inflammatory Bowel Disease. Inflamm Bowel Dis 2020; 26:1330-1339. [PMID: 32322878 DOI: 10.1093/ibd/izaa065] [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: 11/26/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Immunomodulators and anti tumor-necrosis-α antibodies (anti-TNFs) have been implicated in increased risk of Epstein-Barr virus (EBV)-driven B-cell lymphoproliferative disorders in inflammatory bowel disease (IBD) patients. However, the underlying mechanisms are poorly understood. METHODS An in-vitro model of lymphoblastoid cell line (LCL) was established by co-incubation of EBV-infected human peripheral blood mononuclear cells (PBMC) with Cyclosporin-A (CSA). After 4 weeks, the resultant LCLs were analyzed by flow cytometry, telomerase activity assay, and next generation sequencing. Subsequently, LCLs were explored in the presence of therapeutic agents for IBD (anti-TNFs, vedolizumab, 6-Mercaptopurine [6MP], methotrexate). Epstein-Barr virus titers were quantitated by real-time polymerase chain reaction. RESULTS In cultures of PBMC with EBV and CSA, LCLs were characterized as an expanded, long lived population of CD58+CD23hi B-cells with high telomerase activity and clonal expansion. Upon addition to the cell cultures, LCL percentages were higher with infliximab (median 19.21%, P = 0.011), adalimumab (median 19.85%, P = 0.003), and early washed-out 6MP (median 30.57%, P = 0.043) compared with PBMC with EBV alone (median 9.61%). However, vedolizumab had no such effect (median 8.97%; P = 0.435). Additionally, LCL expansion was accompanied by increase in intracellular, rather than extracellular, EBV viral copies. Compared with PBMC with EBV alone, high levels of LCL were subsequently observed after triple depletion of NK cells, CD4+ T cells, and CD8+ T cells (median 52.8% vs 16.4%; P = 0.046) but also in cultures depleted solely of CD4+ T cells (median 30.7%, P = 0.046). CONCLUSIONS These results suggest that both anti-TNFs and 6MP, but not vedolizumab, propagate EBV-driven lymphoblastoid transformation in an in vitro model of lymphoma. This model may prove useful for studying mechanisms underlying proneoplastic viral immune interactions of novel drugs in IBD therapy.
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Affiliation(s)
- Nina Levhar
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Bella Ungar
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ella Fudim
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Miri Yavzori
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Orit Picard
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ninette Amariglio
- Cancer Research Center, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yehuda Chowers
- Rambam Health Care Campus, Bruce & Ruth Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Yonat Shemer-Avni
- Shraga Segal Department of Microbiology, Immunology and Genetics, Soroka Medical Center Beer-Sheva, Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Israel
| | - Ren Mao
- First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Min-Hu Chen
- First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ziyin Ye
- First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Rami Eliakim
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Shomron Ben-Horin
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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23
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Hasnis E, Dahan A, Khoury W, Duek D, Fisher Y, Beny A, Shaked Y, Chowers Y, Half EE. Intratumoral HLA-DR -/CD33 +/CD11b + Myeloid-Derived Suppressor Cells Predict Response to Neoadjuvant Chemoradiotherapy in Locally Advanced Rectal Cancer. Front Oncol 2020; 10:1375. [PMID: 32903466 PMCID: PMC7435035 DOI: 10.3389/fonc.2020.01375] [Citation(s) in RCA: 1] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 06/30/2020] [Indexed: 12/16/2022] Open
Abstract
Capecitabine-based neoadjuvant chemoradiation therapy (nCRT) is currently the mainstay of treatment for locally advanced rectal cancer (LARC), prior to surgical tumor removal. While response to this treatment is partial, it carries significant risk of side effects. As of today, there is no accepted model to predict tumor response, and allow for patient stratification. The level of circulating Myeloid-derived suppressor cells (MDSCs), a subpopulation of early myeloid cells (EMCs), has been shown to correlate with prognosis and response to therapy in advanced colon cancer, but their role in LARC is not clear. We sought to study the effect of intratumoral and circulating levels of different EMCs subpopulations including MDSCs on response to nCRT. We analyzed tumor, normal mucosa, and peripheral blood samples from 25 LARC patients for their different EMCs subpopulation before and after nCRT, and correlated them with degree of pathologic response, as determined postoperatively. In addition, we compared LARC patient to 10 healthy donors and 6 metastatic patients. CD33+HLA-DR−CD16−CD11b+EMCs in the circulation of LARC patients were found to inhibit T-cell activation. Furthermore, elevated levels of CD33+HLA-DR− myeloid cells were found in the tumor relative to normal mucosa, but not in the circulation when compared to healthy subjects. Moreover, intratumoral, but not circulating levels of MDSCs correlated with clinical stage and response to therapy in patients treated with nCRT, with high levels of MDSCs significantly predicting poor response to nCRT. Importantly, therapy by itself, had significant differential effects on MDSC levels, leading to increased circulating MDSCs, concomitantly with decreasing intratumoral MDSCs. Our results suggest that high levels of intratumoral, but not circulating MDSCs may confer drug resistance due to immunomodulatory effects, and serve as a biomarker for patient stratification and decision-making prior to nCRT.
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Affiliation(s)
- Erez Hasnis
- Department of Gastroenterology, Rambam HealthCare Campus, Haifa, Israel.,Cancer Center, Sanford-Burnham-Prebys Medical Discovery Institute, San Diego, CA, United States
| | - Aviva Dahan
- Department of Gastroenterology, Rambam HealthCare Campus, Haifa, Israel
| | - Wissam Khoury
- Department of Colorectal Surgery, Rambam HealthCare Campus, Haifa, Israel
| | - Daniel Duek
- Department of Colorectal Surgery, Rambam HealthCare Campus, Haifa, Israel
| | - Yael Fisher
- Department of Pathology, Rambam HealthCare Campus, Haifa, Israel
| | - Alex Beny
- Department of Oncology, Rambam HealthCare Campus, Haifa, Israel
| | - Yuval Shaked
- Department of Cell Biology and Cancer Science, Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Yehuda Chowers
- Department of Gastroenterology, Rambam HealthCare Campus, Haifa, Israel
| | - Elizabeth E Half
- Department of Gastroenterology, Rambam HealthCare Campus, Haifa, Israel
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24
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Zidany H, Waterman M, Toledano K, Chowers Y, Markovits D, Karban A, Balbir-Gurman A, Braun-Moscovici Y. THU0458 HIGH PREVALENCE OF JOINT HYPERMOBILITY IN INFLAMMATORY BOWEL DISEASE PATIENTS WITH PAIN UNRESPONSIVE TO BOWEL-TARGETED THERAPY. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.4767] [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] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:Musculoskeletal manifestations occur in 20-50% of patients (pts) with inflammatory bowel disease (IBD). A substantial number of patients complain of non-inflammatory musculoskeletal pain.Objectives:To assess the incidence of joint hypermobility (JHM), benign joint hypermobility syndrome (BJHS) among patients with inflammatory bowel disease (IBD) examined in the inter-disciplinary rheumatology service at a tertiary referral center and the impact on IBD manifestations and outcome.Methods:Medical records of 180 consecutive IBD pts referred to the inter-disciplinary clinic were retrospectively reviewed. Data regarding age, gender, diagnosis, disease duration, clinical and laboratory features, previous and current therapy, Harvey-Brandshaw Index were entered into a database and analyzed. Beighton’s scoring of ≥4/9 was used to define patients with JHM. The 1998 Brighton’s criteria were used to identify patients with BJHS. Outcome was defined as improvement of joint pain. The statistical methods used included descriptive statistics, T test, Spearman’s correlation and multiple logistic regression analysis.Results:Forty-six patients (mean(SD) age 36.2(12.4), disease duration 13.9(8.8) years) out of 180 IBD patients (mean(SD) age 40.4(14.3), disease duration 15.7(9.1) years) fulfilled the criteria for JHM. Twelve patients had active inflammatory joint disease (2 with axial involvement, 10 with peripheral joint disease and 2 with axial and peripheral joint involvement). The other 32 answered both major criteria for BJHS. The median Beighton scoring was 7 (range 5-9). Most of them were on biological treatment. Patients with JHM suffered frequently of arthralgia and abdominal pain, in spite of endoscopic remission and normal levels of calprotectin and inflammatory markers (p=0.02, r=0.17). JHM and BJHS were associated with poorer outcome (p=0.004, r=0.2). In a multiple logistic regression analysis, only JHM reached borderline significance for predicting worse outcome.Conclusion:Joint and abdominal pain did not improve with immunomodulatory therapy in IBD patients with JHM. JHM may have a negative impact on achievement of clinical remission, in a significant subset of IBD patients. Rheumatologists and gastroenterologists should be aware of this.Disclosure of Interests: :Haya Zidany: None declared, Matti Waterman: None declared, Kohava Toledano: None declared, Yehuda Chowers: None declared, Doron Markovits: None declared, Amir Karban: None declared, Alexandra Balbir-Gurman Consultant of: Novartis, Yolanda Braun-Moscovici: None declared
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25
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Bar-Yoseph H, Daoud H, Ben Hur D, Chowers Y, Waterman M. Does early corticosteroid therapy affect prognosis in IBD patients hospitalized with Clostridioides difficile infection? Int J Colorectal Dis 2020; 35:513-519. [PMID: 31927638 DOI: 10.1007/s00384-019-03502-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/29/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Corticosteroids (CS) therapy to Clostridioides difficile infection (CDI) in inflammatory bowel disease (IBD) flares may worsen CDI outcomes. AIM Assess the impact of early CS exposure on outcomes of IBD patients diagnosed with CDI. METHODS Retrospective study of IBD patients admitted with first-time CDI between 2002 and 2018. Comparisons were made based on CS exposure 48 h from admission. Patients were further subdivided to 5 groups based on CS-antibiotics temporal exposure. The primary outcome was all-cause mortality or colectomy within 3 months. Secondary outcomes were colectomy and mortality rates at 1 year, length of stay, readmissions, bacteremia, and diarrhea improvement by day 7/discharge. Cox proportional hazard model and Kaplan-Meier curves were used to assess the effects on survival. Logistic and ordinal regressions were used to assess primary and secondary outcomes. RESULTS One hundred thirteen patients (64 CD, 46 UC, and 3 IBDU) were included, 82 (72.5%) received early CS. At baseline, CRP was significantly lower and albumin was higher in the group not exposed to early CS. At 3 months, 4 (4.8%) patients required colectomy and 6 (5.8%) died (p = NS). Length of stay was significantly reduced among patients not exposed to early CS. All other endpoints were not associated with CS exposure. In subgroup analysis, the primary outcome was not significantly different among the sub-groups. Mortality rate at 1 year was significantly lower in patients who did not receive antibiotics for CDI. CONCLUSION Early CS therapy in IBD patients hospitalized with CDI is not associated with worse clinical outcomes. However, additional prospective research is required.
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Affiliation(s)
- Haggai Bar-Yoseph
- Department of Gastroenterology, Rambam Health Care Campus, 8th Haalia Hashnia st., 3109601, Haifa, Israel.
- Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.
| | - Haneen Daoud
- Department of Internal Medicine H, Rambam Health Care Campus, 8th Haalia Hashnia st., 3109601, Haifa, Israel
| | - Dana Ben Hur
- Department of Gastroenterology, Rambam Health Care Campus, 8th Haalia Hashnia st., 3109601, Haifa, Israel
- Department of Internal Medicine H, Rambam Health Care Campus, 8th Haalia Hashnia st., 3109601, Haifa, Israel
| | - Yehuda Chowers
- Department of Gastroenterology, Rambam Health Care Campus, 8th Haalia Hashnia st., 3109601, Haifa, Israel
- Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
- Clinical Research Institute, Rambam Health Care Campus, Haifa, Israel
| | - Matti Waterman
- Department of Gastroenterology, Rambam Health Care Campus, 8th Haalia Hashnia st., 3109601, Haifa, Israel
- Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
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26
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Bar-Gil Shitrit A, Ben-Ya'acov A, Siterman M, Waterman M, Hirsh A, Schwartz D, Zittan E, Adler Y, Koslowsky B, Avni-Biron I, Chowers Y, Ron Y, Israeli E, Ungar B, Yanai H, Maharshak N, Ben-Horin S, Eliakim R, Dotan I, Goldin E, Kopylov U. Safety and effectiveness of ustekinumab for induction of remission in patients with Crohn's disease: A multicenter Israeli study. United European Gastroenterol J 2020; 8:418-424. [PMID: 32213026 DOI: 10.1177/2050640620902956] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [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] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Ustekinumab is an effective treatment of Crohn's disease (CD). Real-world data addressing the efficacy and safety of ustekinumab are scarce. AIM Our aim was to assess the safety and efficacy of ustekinumab in a large national patient cohort. METHODS A prospective multicenter study, in which we followed patients with active CD treated with ustekinumab for 24 weeks. Induction dose was intravenous ranging from 260 to 520 mg, according to body weight, followed by 90 mg doses given subcutaneously every 8 weeks. Clinical response was defined as a reduction of at least 1 severity category, as defined by Harvey-Bradshaw index (HBI). Patients with HBI < 5 were considered to be in clinical remission. Patients who stopped needing steroids at week 24 were defined as being in steroid-free clinical remission. RESULTS A total of 106 CD patients from eight Israeli centers were included. All patients were previously exposed to at least one biological agent. Our cohort consisted of 65 (61.3%) females. Mean age was 41 ± 14 years with an average disease duration of 12.2 ± 8 years. A total of 96 (90.5%) patients continued treatment throughout week 24. Clinical response was observed in 52% of these patients with mean HBI reduction from 8.34 ± 3.8 to 6.8 ± 4.4 at week 24 (p = 0.001). Clinical remission was achieved in 33 patients (31.1%). Moreover, the number of patients requiring steroid treatment was reduced by 66% at week 24. Out of 106 patients, 11 patients (10.4%) discontinued treatment: 3 due to adverse events (2.8%), 7 due to a lack of response, and 1 who was lost to follow-up. Following 24 weeks of treatment, 15 patients reported minor adverse events. CONCLUSIONS In a large real-world Israeli cohort of non-naïve-to-biological-treatment CD patients, ustekinumab was effective and safe in induction of clinical remission with a significant reduction in the number of patients requiring steroid treatment.
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Affiliation(s)
- Ariella Bar-Gil Shitrit
- Digestive Diseases Institute, Shaare Zedek Medical Center, affiliated with Faculty of Medicine, The Hebrew University, Jerusalem, Israel
| | - Ami Ben-Ya'acov
- Digestive Diseases Institute, Shaare Zedek Medical Center, affiliated with Faculty of Medicine, The Hebrew University, Jerusalem, Israel
| | - Matan Siterman
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Matti Waterman
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Ayal Hirsh
- Inflammatory Bowel Disease Center, Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Doron Schwartz
- Department of Gastroenterology, Soroka Medical Center, Beer Sheva, Israel
| | - Eran Zittan
- Inflammatory Bowel Disease Unit, Ellen and Pinchas Mamber Institute of Gastroenterology and Liver Diseases, Emek Medical Center, Afula, Israel
| | - Yehonatan Adler
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Israel
| | - Benjamin Koslowsky
- Digestive Diseases Institute, Shaare Zedek Medical Center, affiliated with Faculty of Medicine, The Hebrew University, Jerusalem, Israel
| | - Irit Avni-Biron
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yehuda Chowers
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Yulia Ron
- Inflammatory Bowel Disease Center, Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Eran Israeli
- Institute of Gastroenterology, Hebrew University Hadassah Medical Center, Jerusalem, Israel
| | - Bella Ungar
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Israel
| | - Henit Yanai
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nitsan Maharshak
- Inflammatory Bowel Disease Center, Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Shomron Ben-Horin
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Israel
| | - Rami Eliakim
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Israel
| | - Iris Dotan
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eran Goldin
- Digestive Diseases Institute, Shaare Zedek Medical Center, affiliated with Faculty of Medicine, The Hebrew University, Jerusalem, Israel
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Israel
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27
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Fujita Y, Khateb A, Li Y, Tinoco R, Zhang T, Bar-Yoseph H, Tam MA, Chowers Y, Sabo E, Gerassy-Vainberg S, Starosvetsky E, James B, Brown K, Shen-Orr SS, Bradley LM, Tessier PA, Ronai ZA. Regulation of S100A8 Stability by RNF5 in Intestinal Epithelial Cells Determines Intestinal Inflammation and Severity of Colitis. Cell Rep 2019; 24:3296-3311.e6. [PMID: 30232010 PMCID: PMC6185744 DOI: 10.1016/j.celrep.2018.08.057] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 07/29/2018] [Accepted: 08/17/2018] [Indexed: 12/11/2022] Open
Abstract
Inflammatory bowel disease (IBD) is prevalent, but the mechanisms underlying disease development remain elusive. We identify a role for the E3 ubiquitin ligase RNF5 in IBD. Intestinal epithelial cells (IECs) express a high level of RNF5, while the colon of Rnf5−/− mice exhibits activated dendritic cells and intrinsic inflammation. Rnf5−/− mice exhibit severe acute colitis following dextran sodium sulfate (DSS) treatment. S100A8 is identified as an RNF5 substrate, resulting in S100A8 ubiquitination and proteasomal-dependent degradation that is attenuated upon inflammatory stimuli. Loss of RNF5 from IECs leads to enhanced S100A8 secretion, which induces mucosal CD4+ T cells, resulting in Th1 pro-inflammatory responses. Administration of S100A8-neutralizing antibodies to DSS-treated Rnf5−/− mice attenuates acute colitis development and increases survival. An inverse correlation between RNF5 and S100A8 protein expression in IECs of IBD patients coincides with disease severity. Collectively, RNF5-mediated regulation of S100A8 stability in IECs is required for the maintenance of intestinal homeostasis. Fujita et al. show that RNF5 regulation of S100A8 stability in intestinal epithelial cells defines the degree of pro-inflammatory response, culminating in severe intestinal inflammation following DSS treatment to Rnf5−/− mice. Neutralizing S100A8 antibodies attenuates acute colitis phenotypes, and inverse RNF5/S100A8 expression coincides with clinical severity in IBD patients.
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Affiliation(s)
- Yu Fujita
- Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA 92037, USA
| | - Ali Khateb
- Technion Integrated Cancer Center, Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, 31096, Israel
| | - Yan Li
- Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA 92037, USA
| | - Roberto Tinoco
- Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA 92037, USA
| | - Tongwu Zhang
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD 20892, USA
| | - Haggai Bar-Yoseph
- Rambam Health Care Campus, Gastroenterology Institute, Haifa, 31096, Israel
| | | | - Yehuda Chowers
- Rambam Health Care Campus, Gastroenterology Institute, Haifa, 31096, Israel
| | - Edmond Sabo
- Pathology Division, Carmel Medical Center, Haifa, 34362, Israel
| | - Shiran Gerassy-Vainberg
- Technion Integrated Cancer Center, Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, 31096, Israel
| | - Elina Starosvetsky
- Technion Integrated Cancer Center, Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, 31096, Israel
| | - Brian James
- Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA 92037, USA
| | - Kevin Brown
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD 20892, USA
| | - Shai S Shen-Orr
- Technion Integrated Cancer Center, Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, 31096, Israel
| | - Linda M Bradley
- Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA 92037, USA
| | - Philippe A Tessier
- Centre de Recherche du Centre Hospitalier de l'Université Laval, Sainte-Foy, Quebec, QC G1V 4G2, Canada
| | - Ze'ev A Ronai
- Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA 92037, USA; Technion Integrated Cancer Center, Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, 31096, Israel.
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Bar-Yoseph H, Pressman S, Blatt A, Gerassy Vainberg S, Maimon N, Starosvetsky E, Ungar B, Ben-Horin S, Shen-Orr SS, Chowers Y. Infliximab-Tumor Necrosis Factor Complexes Elicit Formation of Anti-Drug Antibodies. Gastroenterology 2019; 157:1338-1351.e8. [PMID: 31401142 DOI: 10.1053/j.gastro.2019.08.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [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: 04/18/2019] [Revised: 07/25/2019] [Accepted: 08/01/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Some patients develop anti-drug antibodies (ADAs), which reduce the efficacy of infliximab, a monoclonal antibody against tumor necrosis factor (TNF), in the treatment of immune-mediated diseases, including inflammatory bowel diseases. ADAs arise inconsistently, and it is not clear what factors determine their formation. We investigated features of the immune system, the infliximab antibody, and its complex with TNF that might contribute to ADA generation. METHODS C57BL/6 mice were given injections of infliximab and recombinant human TNF or infliximab F(ab')2 fragments. Blood samples were collected every 2-3 days for 2 weeks and weekly thereafter for up to 6 weeks; infliximab-TNF complexes and ADAs were measured by enzyme-linked immunosorbent assay (ELISA). Intestinal biopsy and blood samples were obtained from patients having endoscopy who had received infliximab therapy for inflammatory bowel diseases; infliximab-TNF complexes were measured with ELISA. Infliximab-specific plasma cells were detected in patient tissue samples by using mass cytometry. We studied activation of innate immune cells in peripheral blood mononuclear cells (PBMCs) from healthy donors incubated with infliximab or infliximab-TNF complexes; toll-like receptors (TLRs) were blocked with antibodies, endocytosis was blocked with the inhibitor PitStop2, and cytokine expression was measured by real-time polymerase chain reaction and ELISAs. Uptake of infliximab and infliximab-TNF complexes by THP-1 cells was measured with confocal microscopy. RESULTS Mice given increasing doses of infliximab produced increasing levels of ADAs. Blood samples from mice given injections of human TNF and infliximab contained infliximab-TNF complexes; complex formation was associated with ADA formation with an area under the curve of 0.944 (95% confidence interval, 0.851-1.000; P = .003). Intestinal tissues from patients, but not blood samples, contained infliximab-TNF complexes and infliximab-specific plasma cells. Incubation of PBMCs with infliximab-TNF complexes resulted in a 4.74-fold increase in level of interleukin (IL) 1β (IL1B) messenger RNA (P for comparison = .005), increased IL1B protein secretion, and a 2.69-fold increase in the expression of TNF messenger RNA (P for comparison = 0.013) compared with control PBMCs. Infliximab reduced only IL1B and TNF expression. Antibodies against TLR2 or TLR4 did not block the increases in IL1B or TNF expression, but endocytosis was required. THP-1 cells endocytosed higher levels of infliximab-TNF complexes than infliximab alone. CONCLUSIONS In mice, we found ADA formation to increase with dose of infliximab given and concentration of infliximab-TNF complexes detected in blood. Based on studies of human intestinal tissues and blood samples, we propose that infliximab-TNF complexes formed in the intestine are endocytosed by and activate innate immune cells, which increase expression of IL1B and TNF and production of antibodies against the drug complex. It is therefore important to optimize the infliximab dose to a level that is effective but does not activate an innate immune response against the drug-TNF complex.
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Affiliation(s)
- Haggai Bar-Yoseph
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel; Bruce Rappaport School of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Sigal Pressman
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Alexandra Blatt
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | | | - Naama Maimon
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel; Bruce Rappaport School of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Elina Starosvetsky
- Bruce Rappaport School of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Bella Ungar
- Department of Gastroenterology, Chaim Sheba Medical Center, Ramat-Gan, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shomron Ben-Horin
- Department of Gastroenterology, Chaim Sheba Medical Center, Ramat-Gan, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shai S Shen-Orr
- Bruce Rappaport School of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Yehuda Chowers
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel; Bruce Rappaport School of Medicine, Technion Israel Institute of Technology, Haifa, Israel; Clinical Research Institute, Rambam Health Care Campus, Haifa, Israel.
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Chowers Y. One Size Does Not Fit All: The Case for Translational Medicine. Rambam Maimonides Med J 2019; 10:RMMJ.10364. [PMID: 30860477 PMCID: PMC6474761 DOI: 10.5041/rmmj.10364] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Therapy for inflammatory bowel diseases (IBD) has developed during recent years. Despite the availability of new therapeutic modalities, overall therapy success remains modest, and complete remission is usually achieved and maintained in approximately 30% of patients only. This observation can be explained by a number of reasons. First, the involvement of multiple genetic loci combined with differential environmental exposures suggests that IBD represent a continuum of disorders rather than distinct homogeneous disease entities. This diversity is translated into different disease course patterns, wherein some patients experience quiescent disease whereas others suffer from a relentless disease course. Hence, basic disease pathogenesis sets the stage for differential treatment responses. To date, IBD therapy is based on immunosuppression which does not take basic disease variability into account. Treatments are prescribed based on statistical considerations related to the response of the average patient in clinical trials rather than on personal considerations. Treatment outcomes can potentially be improved if physiologic considerations are integrated into the drug selection process. In one approach, drugs can be targeted at known patient dysfunctional processes such as in the case of patients carrying autophagy-related genetic polymorphisms being treated with rapamycin, a drug that inhibits mTOR inhibitor and enhances autophagy. Another alternative would be to use a systems approach to perform unsupervised, high-throughput screening in order to derive predictive treatment biomarkers and mechanistic insights associated with response to specific drug therapy. Additional predictive markers for drug safety are needed as well. Caveats and directions for needed future studies are outlined.
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Affiliation(s)
- Yehuda Chowers
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
- E-mail:
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Gaujoux R, Starosvetsky E, Maimon N, Vallania F, Bar-Yoseph H, Pressman S, Weisshof R, Goren I, Rabinowitz K, Waterman M, Yanai H, Dotan I, Sabo E, Chowers Y, Khatri P, Shen-Orr SS. Cell-centred meta-analysis reveals baseline predictors of anti-TNFα non-response in biopsy and blood of patients with IBD. Gut 2019; 68:604-614. [PMID: 29618496 PMCID: PMC6580771 DOI: 10.1136/gutjnl-2017-315494] [Citation(s) in RCA: 131] [Impact Index Per Article: 26.2] [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: 10/20/2017] [Revised: 12/19/2017] [Accepted: 01/16/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Although anti-tumour necrosis factor alpha (anti-TNFα) therapies represent a major breakthrough in IBD therapy, their cost-benefit ratio is hampered by an overall 30% non-response rate, adverse side effects and high costs. Thus, finding predictive biomarkers of non-response prior to commencing anti-TNFα therapy is of high value. DESIGN We analysed publicly available whole-genome expression profiles of colon biopsies obtained from multiple cohorts of patients with IBD using a combined computational deconvolution-meta-analysis paradigm which allows to estimate immune cell contribution to the measured expression and capture differential regulatory programmes otherwise masked due to variation in cellular composition. Insights from this in silico approach were experimentally validated in biopsies and blood samples of three independent test cohorts. RESULTS We found the proportion of plasma cells as a robust pretreatment biomarker of non-response to therapy, which we validated in two independent cohorts of immune-stained colon biopsies, where a plasma cellular score from inflamed biopsies was predictive of non-response with an area under the curve (AUC) of 82%. Meta-analysis of the cell proportion-adjusted gene expression data suggested that an increase in inflammatory macrophages in anti-TNFα non-responding individuals is associated with the upregulation of the triggering receptor expressed on myeloid cells 1 (TREM-1) and chemokine receptor type 2 (CCR2)-chemokine ligand 7 (CCL7) -axes. Blood gene expression analysis of an independent cohort, identified TREM-1 downregulation in non-responders at baseline, which was predictive of response with an AUC of 94%. CONCLUSIONS Our study proposes two clinically feasible assays, one in biopsy and one in blood, for predicting non-response to anti-TNFα therapy prior to initiation of treatment. Moreover, it suggests that mechanism-driven novel drugs for non-responders should be developed.
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Affiliation(s)
- Renaud Gaujoux
- Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel,CytoReason
| | - Elina Starosvetsky
- Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Naama Maimon
- Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel,Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Francesco Vallania
- Division of Biomedical Informatics Research, Department of Medicine, Stanford University, Palo Alto, California, USA,Stanford Institute for Immunity Transplantation and Infection, Department of Medicine, Stanford University, Palo Alto, California, USA
| | - Haggai Bar-Yoseph
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Sigal Pressman
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Roni Weisshof
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Idan Goren
- Department of Gastroenterology and Liver Diseases, IBD Center, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Keren Rabinowitz
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel
| | - Matti Waterman
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Henit Yanai
- Department of Gastroenterology and Liver Diseases, IBD Center, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel
| | - Iris Dotan
- Department of Gastroenterology and Liver Diseases, IBD Center, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel
| | - Edmond Sabo
- Department of Pathology, Rambam Health Care Campus, Haifa, Israel
| | - Yehuda Chowers
- Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel,Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Purvesh Khatri
- Division of Biomedical Informatics Research, Department of Medicine, Stanford University, Palo Alto, California, USA,Stanford Institute for Immunity Transplantation and Infection, Department of Medicine, Stanford University, Palo Alto, California, USA
| | - Shai S Shen-Orr
- Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Ben-Horin S, Zhao Y, Guo J, Mao R, Novack L, Sergienko R, Zhang J, Kobayashi T, Hibi T, Chowers Y, Colombel JF, Peyrin-Biroulet L, Kaplan G, Chen MH. Efficacy of biological drugs in short-duration versus long-duration inflammatory bowel disease: a protocol for a systematic review and an individual-patient level meta-analysis of randomised controlled trials. BMJ Open 2019; 9:e024222. [PMID: 30782731 PMCID: PMC6352773 DOI: 10.1136/bmjopen-2018-024222] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 09/15/2018] [Accepted: 12/04/2018] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Crohn's disease (CD) and ulcerative colitis (UC) are remitting-relapsing inflammatory diseases often culminating in disease complications and/or need for surgery. Biologic monoclonal antibody drugs ('Biologics') are efficacious for both diseases, but there are no systematic assessments of their efficacy if administered early after disease onset ('top-down' strategy) vis-à-vis later in the course of disease ('step-up' approach). METHODS AND ANALYSIS Electronic databases (MEDLINE, EMBASE/EMBASE classic Cochrane CENTRAL register of controlled trials, the Cochrane IBD Group Specialised Trials Register and Clinicaltrials.gov registry) will be searched to identify all randomised placebo-controlled clinical trials of food and drug administration (FDA)-approved biologics for CD and UC (by March 2016). Two independent reviewers will screen identified papers, extract data and assess the risk of bias according to the Cochrane Handbook for Systematic Reviews of Interventions. Individual-patient-level data (IPD) will be extracted from the identified trials through data-sharing platforms for pharmaceutical companies' sponsored trials and by contacting principal investigators of independent investigator-initiated trials. We will analyse induction of remission in patients with early-disease (<18 months since disease onset) versus patients with longer disease duration, using a generalised linear mixed effect model and by a two-stage approach using coefficient for the treatment-by-subgroup interaction within each trial. We will perform receiver operator curve analysis of optimal disease duration for response. Analyses will be separate for CD and UC. This first-of-its-kind meta-analysis at IPD level of interaction of disease duration with the response to biologics in UC and CD may elucidate the impact of early initiation of biologics, which is of paramount importance for clinical practice and management strategies of inflammatory bowel disease. ETHICS AND DISSEMINATION This meta-analysis was approved by the Ethics Committee of the First Affiliated Hospital of Sun Yat-sen University. Findings will be published in peer-reviewed journal and disseminated via scientific meetings and links with organisations. PROSPERO REGISTRATION NUMBER CRD42018041961.
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Affiliation(s)
- Shomron Ben-Horin
- Department of Gastroenterology, First affiliated Hospital of the Sun Yatsen University, Guangzhou, China
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Yue Zhao
- Department of Gastroenterology, First affiliated Hospital of the Sun Yatsen University, Guangzhou, China
| | - Jing Guo
- Department of Gastroenterology, First affiliated Hospital of the Sun Yatsen University, Guangzhou, China
| | - Ren Mao
- Department of Gastroenterology, First affiliated Hospital of the Sun Yatsen University, Guangzhou, China
| | - Lena Novack
- Department of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ruslan Sergienko
- Department of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Jian Zhang
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Taku Kobayashi
- Department of Gastroenterology, Kitasato Institute Hospital, Tokyo, Japan
| | - Toshifumi Hibi
- Department of Gastroenterology, Kitasato Institute Hospital, Tokyo, Japan
| | - Yehuda Chowers
- Department of Gastroenterology, Rambam Health Care Campus, Bruce & Ruth Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel
| | - Jean Frederic Colombel
- Helmsley Inflammatory Bowel Disease Center, Icahn School of Medicine, Mount Sinai Hospital, New York City, New York, USA
| | | | - Gilaad Kaplan
- Department of Gastroenterology, University of Calgary, Calgary, Canada
| | - Min-Hu Chen
- Department of Gastroenterology, First affiliated Hospital of the Sun Yatsen University, Guangzhou, China
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Ben-Horin S, Van Assche G, Chowers Y, Fudim E, Ungar B, Picard O, Yavzori M, Kopylov U, Mao R, Chen MH, Peled Y, Gueta I, Eliakim R, Loebstein R, Markovits N. Pharmacokinetics and Immune Reconstitution Following Discontinuation of Thiopurine Analogues: Implications for Drug Withdrawal Strategies. J Crohns Colitis 2018; 12:1410-1417. [PMID: 30169593 DOI: 10.1093/ecco-jcc/jjy122] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [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: 02/05/2023]
Abstract
BACKGROUND AND AIMS Discontinuation of thiopurine analogues is common prior to live vaccines, during infection or when de-escalating therapy. Data regarding clearance of active metabolites and immune re-constitution is scant. We aimed to determine drug elimination and immune re-constitution following thiopurine cessation. METHODS The elimination kinetics of 6-thioguanine nucleotides (6-TGN) were determined in nine inflammatory bowel disease [IBD] patients discontinuing thiopurines. Immune reconstitution was evaluated by toxic shock syndrome toxin 1 [TSST1] or anti-CD3 [OKT3]-induced CD4+ T-cell proliferation, following an initial exposure to TSST1 and 6-mercaptopurine [6MP], separately or combined. RESULTS All patients discontinuing thiopurines displayed first-order elimination kinetics of 6-TGN, with a median elimination half-life of 6.8 days [interquartile range 5.9-8.4]. Resting CD4+ T-cells exposed to 6MP preserved their response to subsequent polyclonal or Vβ2+-preferential stimulation. By contrast, exposure of TSST1-activated CD4+ T-cells to 6MP inhibited their subsequent Vβ2+clonal response to further stimulation [p = 0.008], whereas overall response to further non-Vβ2-selective stimulation with OKT3 was unaltered [p = 0.9]. CONCLUSIONS Upon 6MP/azathioprine discontinuation, a 6-TGN elimination half-life of less than 10 days is expected in most patients. Immune reconstitution, however, may take longer for T-cell clones exposed to stimulation during thiopurine treatment. These findings may be useful when considering thiopurine cessation.
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Affiliation(s)
- Shomron Ben-Horin
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer & Sackler School of Medicine, Tel-Aviv University, Israel.,Department of Gastroenterology, First Affiliated Hospital, Sun YatSen University, Guangzhou, China
| | - Gert Van Assche
- Division of Gastroenterology and Hepatology, University Hospitals Leuven, Belgium
| | - Yehuda Chowers
- Rambam Health Care Campus & Bruce Rappaport School of Medicine, Technion Institute of Technology, Haifa, Israel
| | - Ella Fudim
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer & Sackler School of Medicine, Tel-Aviv University, Israel
| | - Bella Ungar
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer & Sackler School of Medicine, Tel-Aviv University, Israel
| | - Orit Picard
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer & Sackler School of Medicine, Tel-Aviv University, Israel
| | - Miri Yavzori
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer & Sackler School of Medicine, Tel-Aviv University, Israel
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer & Sackler School of Medicine, Tel-Aviv University, Israel
| | - Ren Mao
- Department of Gastroenterology, First Affiliated Hospital, Sun YatSen University, Guangzhou, China
| | - Min-Hu Chen
- Department of Gastroenterology, First Affiliated Hospital, Sun YatSen University, Guangzhou, China
| | - Yael Peled
- The Olga and Lev Leviev Heart Center, Sheba Medical Center Tel Hashomer & Sackler School of Medicine, Tel-Aviv University, Israel
| | - Itai Gueta
- Institute of Clinical Pharmacology, Sheba Medical Center Tel Hashomer, Tel-Aviv University, Israel
| | - Rami Eliakim
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer & Sackler School of Medicine, Tel-Aviv University, Israel
| | - Ronen Loebstein
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer & Sackler School of Medicine, Tel-Aviv University, Israel
| | - Noa Markovits
- The Institute of Clinical Pharmacology, Sheba Medical Center Tel Hashomer & Sackler School of Medicine, Tel-Aviv University, Israel
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Friedman MY, Leventer-Roberts M, Rosenblum J, Zigman N, Goren I, Mourad V, Lederman N, Cohen N, Matz E, Dushnitzky DZ, Borovsky N, Hoshen MB, Focht G, Avitzour M, Shachar Y, Chowers Y, Eliakim R, Ben-Horin S, Odes S, Schwartz D, Dotan I, Israeli E, Levi Z, Benchimol EI, Balicer RD, Turner D. Development and validation of novel algorithms to identify patients with inflammatory bowel diseases in Israel: an epi-IIRN group study. Clin Epidemiol 2018; 10:671-681. [PMID: 29922093 PMCID: PMC5995295 DOI: 10.2147/clep.s151339] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background Before embarking on administrative research, validated case ascertainment algorithms must be developed. We aimed at developing algorithms for identifying inflammatory bowel disease (IBD) patients, date of disease onset, and IBD type (Crohn's disease [CD] vs ulcerative colitis [UC]) in the databases of the four Israeli Health Maintenance Organizations (HMOs) covering 98% of the population. Methods Algorithms were developed on 5,131 IBD patients and 2,072 controls, following independent chart review (60% CD and 39% UC). We reviewed 942 different combinations of clinical parameters aided by mathematical modeling. The algorithms were validated on an independent cohort of 160,000 random subjects. Results The combination of the following variables achieved the highest diagnostic accuracy: IBD-related codes, alone if more than five to six codes or combined with purchases of IBD-related medications (at least three purchases or ≥3 months from the first to last purchase) (sensitivity 89%, specificity 99%, positive predictive value [PPV] 92%, negative predictive value [NPV] 99%). A look-back period of 2-5 years (depending on the HMO) without IBD-related codes or medications best determined the date of diagnosis (sensitivity 83%, specificity 68%, PPV 82%, NPV 70%). IBD type was determined by the majority of CD/UC codes of the three recent contacts or the most recent when less than three contacts were recorded (sensitivity 92%, specificity 97%, PPV 97%, NPV 92%). Applying these algorithms, a total of 38,291 IBD patients were residing in Israel, corresponding to a prevalence rate of 459/100,000 (0.46%). Conclusion The application of the validated algorithms to Israel's administrative databases will now create a large and accurate ongoing population-based cohort of IBD patients for future administrative studies.
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Affiliation(s)
- Mira Y Friedman
- The Juliet Keidan Institute of Pediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel.,Braun School of Public and Community Medicine, The Hebrew University - Hadassah Medical Center, Jerusalem, Israel
| | | | | | - Nir Zigman
- Maccabi Healthcare Services, Tel Aviv, Israel
| | - Iris Goren
- Maccabi Healthcare Services, Tel Aviv, Israel
| | | | | | | | - Eran Matz
- Leumit Health Services, Tel Aviv, Israel
| | | | | | - Moshe B Hoshen
- Clalit Research Institute, Chief's Office, Clalit Health Services, Tel Aviv, Israel
| | - Gili Focht
- The Juliet Keidan Institute of Pediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Malka Avitzour
- The Juliet Keidan Institute of Pediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yael Shachar
- The Juliet Keidan Institute of Pediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yehuda Chowers
- Department of Gastroenterology, Rambam Health Care Campus, Bruce Rappaport School of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Rami Eliakim
- Department of Gastroenterology, Chaim Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shomron Ben-Horin
- Department of Gastroenterology, Chaim Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shmuel Odes
- Department of Gastroenterology and Hepatology, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Doron Schwartz
- Department of Gastroenterology and Hepatology, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Iris Dotan
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel
| | - Eran Israeli
- Institute of Gastroenterology and Liver Diseases, Hadassah Medical Center, Hebrew University, Jerusalem, Israel
| | - Zohar Levi
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel
| | - Eric I Benchimol
- CHEO Inflammatory Bowel Disease Centre, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.,Department of Pediatrics and School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada.,Institute for Clinical Evaluative Sciences, Ottawa, ON, Canada
| | - Ran D Balicer
- Clalit Research Institute, Chief's Office, Clalit Health Services, Tel Aviv, Israel
| | - Dan Turner
- The Juliet Keidan Institute of Pediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
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Ungar B, Kopylov U, Yavzori M, Fudim E, Picard O, Lahat A, Coscas D, Waterman M, Haj-Natour O, Orbach-Zingboim N, Mao R, Chen M, Chowers Y, Eliakim R, Ben-Horin S. Association of Vedolizumab Level, Anti-Drug Antibodies, and α4β7 Occupancy With Response in Patients With Inflammatory Bowel Diseases. Clin Gastroenterol Hepatol 2018; 16:697-705.e7. [PMID: 29223444 DOI: 10.1016/j.cgh.2017.11.050] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [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: 10/12/2017] [Revised: 11/15/2017] [Accepted: 11/17/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There are few data available on the real-life pharmacokinetic and pharmacodynamics features of vedolizumab, a monoclonal antibody against integrin α4β7. We performed a prospective study of patients with inflammatory bowel diseases (IBDs) treated with vedolizumab to determine serum drug concentrations, formation of antivedolizumab antibodies (AVAs), and integrin α4β7 saturation. METHODS We performed a prospective study of 106 patients with IBD (67 with Crohn's disease and 39 with ulcerative colitis) treated with vedolizumab from September 2014 through March 2017 at 2 tertiary medical centers in Israel. Clinical data and serum samples were collected before and during induction and maintenance therapy. Clinical remission was defined as Harvey-Bradshaw index scores below 5 or as Simple Clinical Colitis Activity Index scores of 3 or less. We measured serum levels of vedolizumab, AVAs, and markers of inflammation. Peripheral blood mononuclear cells were obtained from some patients at designated trough time points and CD3+ CD45RO+ T cells were isolated from 36 samples. Cells were incubated with fluorescent-conjugated vedolizumab and flow cytometry was used to quantify α4β7 integrin saturation. We also performed flow cytometry analyses of CD3+ CD45RO+ lamina propria T cells isolated from intestinal mucosa of patients without IBD (non-IBD controls, n = 6), patients with IBD not treated with vedolizumab (untreated IBD controls, n = 8), and patients with IBD treated with vedolizumab (n = 15). RESULTS Clinical remission was achieved by 48 of 106 patients (45%) by week 6 and 50 of 106 patients (48%) by week 14 of treatment. The median level of vedolizumab at week 6 was higher in patients in clinical remission (40.2 μg/mL) than in patients with active disease (29.7 μg/mL; P = .05). The median serum level of vedolizumab was significantly higher in patients with a normal level of C-reactive protein (21.8 μg/mL vedolizumab) vs the level in those with a high level of C-reactive protein (11.9 μg/mL vedolizumab) during maintenance treatment (P = .0006). The other clinical outcomes measured were not associated with median serum level of vedolizumab at any time point examined. AVAs were detected in 17% of patients during induction therapy and 3% of patients during maintenance therapy, but did not correlate with clinical outcomes. Flow-cytometry analysis of peripheral blood memory T cells (n = 36) showed near-complete occupancy of α4β7 integrin at weeks 2 and 14 and during the maintenance phase, regardless of response status or drug levels. Most intestinal CD3+CD45RO+ memory T cells of healthy and IBD controls expressed α4β7 (72%; interquartile range, 56%-81%). In contrast, free α4β7 was detectable on only 5.6% of intestinal memory cells (interquartile range, 4.4%-11.2%) (P < .0001) from vedolizumab-treated patients, regardless of response. CONCLUSIONS In a prospective study of real-life patients with IBD, we associated vedolizumab drug levels with remission and inflammatory marker level. Integrin α4β7 was blocked in almost all T cells from patients treated with vedolizumab, regardless of serum level of the drug or response to treatment. These findings indicate a need to explore alternative mechanisms that prevent response to vedolizumab.
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Affiliation(s)
- Bella Ungar
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Miri Yavzori
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Ella Fudim
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Orit Picard
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Adi Lahat
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Daniel Coscas
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Matti Waterman
- Rambam Health Care Campus, Bruce and Ruth Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Ola Haj-Natour
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Noam Orbach-Zingboim
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Ren Mao
- The First Affiliated Hospital of Sun-Yatsen University, Guangzhou, China
| | - Minhu Chen
- The First Affiliated Hospital of Sun-Yatsen University, Guangzhou, China
| | - Yehuda Chowers
- Rambam Health Care Campus, Bruce and Ruth Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Rami Eliakim
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Shomron Ben-Horin
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel; The First Affiliated Hospital of Sun-Yatsen University, Guangzhou, China
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35
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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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36
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Gerassy-Vainberg S, Blatt A, Danin-Poleg Y, Gershovich K, Sabo E, Nevelsky A, Daniel S, Dahan A, Ziv O, Dheer R, Abreu MT, Koren O, Kashi Y, Chowers Y. Radiation induces proinflammatory dysbiosis: transmission of inflammatory susceptibility by host cytokine induction. Gut 2018; 67:97-107. [PMID: 28438965 DOI: 10.1136/gutjnl-2017-313789] [Citation(s) in RCA: 168] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 03/20/2017] [Accepted: 04/03/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Radiation proctitis (RP) is a complication of pelvic radiotherapy which affects both the host and microbiota. Herein we assessed the radiation effect on microbiota and its relationship to tissue damage using a rectal radiation mouse model. DESIGN We evaluated luminal and mucosa-associated dysbiosis in irradiated and control mice at two postradiation time points and correlated it with clinical and immunological parameters. Epithelial cytokine response was evaluated using bacterial-epithelial co-cultures. Subsequently, germ-free (GF) mice were colonised with postradiation microbiota and controls and exposed to radiation, or dextran sulfate-sodium (DSS). Interleukin (IL)-1β correlated with tissue damage and was induced by dysbiosis. Therefore, we tested its direct role in radiation-induced damage by IL-1 receptor antagonist administration to irradiated mice. RESULTS A postradiation shift in microbiota was observed. A unique microbial signature correlated with histopathology. Increased colonic tumor necrosis factor (TNF)α, IL-1β and IL-6 expression was observed at two different time points. Adherent microbiota from RP differed from those in uninvolved segments and was associated with tissue damage. Using bacterial-epithelial co-cultures, postradiation microbiota enhanced IL-1β and TNFα expression compared with naïve microbiota. GF mice colonisation by irradiated microbiota versus controls predisposed mice to both radiation injury and DSS-induced colitis. IL-1 receptor antagonist administration ameliorated intestinal radiation injury. CONCLUSIONS The results demonstrate that rectal radiation induces dysbiosis, which transmits radiation and inflammatory susceptibility and provide evidence that microbial-induced radiation tissue damage is at least in part mediated by IL-1β. Environmental factors may affect the host via modifications of the microbiome and potentially allow for novel interventional approaches via its manipulation.
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Affiliation(s)
- Shiran Gerassy-Vainberg
- Department of Gastroenterology, Rambam Health Care Campus, Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Faculty of Biotechnology and Food Engineering, Technion-Israel Institute of Technology, Haifa, Israel
| | - Alexandra Blatt
- Department of Gastroenterology, Rambam Health Care Campus, Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Yael Danin-Poleg
- Faculty of Biotechnology and Food Engineering, Technion-Israel Institute of Technology, Haifa, Israel
| | - Katya Gershovich
- Department of Gastroenterology, Rambam Health Care Campus, Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Edmond Sabo
- Department of Pathology, Rambam Medical Center, Haifa, Israel
| | - Alex Nevelsky
- Radiation Unit, Department of Oncology, Rambam Medical Center, Haifa, Israel
| | - Shahar Daniel
- Radiation Unit, Department of Oncology, Rambam Medical Center, Haifa, Israel
| | - Aviva Dahan
- Department of Gastroenterology, Rambam Health Care Campus, Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Oren Ziv
- Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Rishu Dheer
- Division of Gastroenterology, University of Miami, Miller School of Medicine, Miami, USA
| | - Maria T Abreu
- Division of Gastroenterology, University of Miami, Miller School of Medicine, Miami, USA
| | - Omry Koren
- Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Yechezkel Kashi
- Faculty of Biotechnology and Food Engineering, Technion-Israel Institute of Technology, Haifa, Israel
| | - Yehuda Chowers
- Department of Gastroenterology, Rambam Health Care Campus, Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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37
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Weisshof R, Chowers Y. [OPTIMIZATION OF TREATMENT BY ANTIBODIES AGAINST TNF-α IN INFLAMMATORY BOWEL DISEASE]. Harefuah 2017; 156:666-669. [PMID: 29072389] [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: 06/07/2023]
Abstract
Treatment selection for inflammatory bowel disease involves many considerations. Anti-TNF - α agents are one of the major available therapeutic tools for these diseases. Loss of response to anti- TNF - α agents is relatively common and results mostly, but not exclusively, from the development of immunogenicity against the drug. Assessment of disease activity in parallel to measurement of drug levels and anti-drug antibodies allows for treatment optimization in patients who develop clinical loss of response. For patients in remission, treatment optimization can be performed by the evaluation of risk factors for disease flare assisted by assessment of drug levels and the presence of antibodies. Various algorithms can be used to make a decision that will lead to better clinical outcomes and a better cost-effectiveness ratio. Professor Yehuda Chowers has received consultancy fees from Abbot and Schering-Plough.
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Affiliation(s)
- Roni Weisshof
- Gastroenterology Department, Rambam Health Care Campus, Haifa Bruce Rappaport School of Medicine, Technion Israel Institute of Technology, Haifa
| | - Yehuda Chowers
- Gastroenterology Department, Rambam Health Care Campus, Haifa Bruce Rappaport School of Medicine, Technion Israel Institute of Technology, Haifa
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38
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Affiliation(s)
- H Bar-Yoseph
- Rambam Health Care Campus, Gastroenterology Institute, Haifa, Israel
| | - Y Chowers
- Rambam Health Care Campus, Gastroenterology Institute, Haifa, Israel
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39
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Davidov Y, Ungar B, Bar-Yoseph H, Carter D, Haj-Natour O, Yavzori M, Chowers Y, Eliakim R, Ben-Horin S, Kopylov U. Association of Induction Infliximab Levels With Clinical Response in Perianal Crohn's Disease. J Crohns Colitis 2017; 11:549-555. [PMID: 28453755 DOI: 10.1093/ecco-jcc/jjw182] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 10/01/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND The association of infliximab [IFX] trough levels with clinical and endoscopic outcomes in inflammatory bowel disease is well established. However, there is scarce data regarding the association of perianal fistula response with IFX. The aim of this study was to establish whether early induction infliximab levels and anti-infliximab antibodies [ATIs] are associated with perianal fistula response. METHODS Consecutive CD patients with perianal fistulae that were treated with IFX between 2008 and 2016 were included in the study. Response was defined as cessation or significant improvement of fistula drainage. Patients with unavailable IFX level or ATI measurements and/or missing clinical follow-up at Week 14 were excluded. RESULTS A total of 36 patients with perianal fistulae were included; 25/36 [69.4%] responded to treatment by Week 14. The median induction IFX levels at Weeks 2, 6 and 14 in the responders group at Week 14 were higher compared with those of the non-responders group [20/5.6 µg/mL, P = 0.0001; 13.3/2.55 µg/mL P = 0.0001; 4.1/0.14 µg/mL, P = 0.01]. On multivariate analysis, IFX leve at Weeks 2 and 6 were significantly associated with fistula response at Weeks 14 and 30. IFX drug levels of 9.25 µg/mL at Week 2 and 7.25 µg/mL at Week 6 were the best predictors of fistula response. CONCLUSION High IFX trough levels during induction are associated with favorable fistula response to anti-TNF treatment. If validated in a larger prospective study, our findings may help guide anti-TNF treatment in patients with perianal CD, and suggest serum level-guided treatment escalation in non-responders or prompt changing of biologic treatment in non-responders.
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Affiliation(s)
- Yana Davidov
- Department of Gastroenterology, Sheba Medical Center, Tel-Aviv, Israel
| | - Bella Ungar
- Department of Gastroenterology, Sheba Medical Center, Tel-Aviv, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv ; Israel
| | - Haggai Bar-Yoseph
- Rambam Health Care Campus and Bruce Rappaport School of Medicine, Technion Israel Institute of Technology, Haifa; Israel
| | - Dan Carter
- Department of Gastroenterology, Sheba Medical Center, Tel-Aviv, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv ; Israel
| | - Ola Haj-Natour
- Department of Gastroenterology, Sheba Medical Center, Tel-Aviv, Israel
| | - Miri Yavzori
- Department of Gastroenterology, Sheba Medical Center, Tel-Aviv, Israel
| | - Yehuda Chowers
- Rambam Health Care Campus and Bruce Rappaport School of Medicine, Technion Israel Institute of Technology, Haifa; Israel
| | - Rami Eliakim
- Department of Gastroenterology, Sheba Medical Center, Tel-Aviv, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv ; Israel
| | - Shomron Ben-Horin
- Department of Gastroenterology, Sheba Medical Center, Tel-Aviv, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv ; Israel
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Tel-Aviv, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv ; Israel
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40
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Khamaysi I, Abu Ammar A, Vasilyev G, Arinstein A, Chowers Y, Zussman E. Differentiation of Pancreatic Cyst Types by Analysis of Rheological Behavior of Pancreatic Cyst Fluid. Sci Rep 2017; 7:45589. [PMID: 28358122 PMCID: PMC5372360 DOI: 10.1038/srep45589] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 02/27/2017] [Indexed: 12/18/2022] Open
Abstract
Differentiation between mucinous and non-mucinous pancreatic cysts is exceedingly important and challenging, particularly as the former bears malignant transformation potential. Pancreatic cyst fluid (PCF)-based diagnostics, including analyses of biochemical markers, as well as cytology, has shown inadequate accuracy. Herein, a preliminary single-center study of 22 PCF samples, collected by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA), assessed the rheological behavior of PCF and its correlation with lesion type. The dependence of PCF shear viscosity on shear rate was found to follow a power law and could be fitted using Ostwald-de Waele model. Three types of flow curves were identified, where two types correlated with non-mucinous cysts, differing by their power law exponent, and the third type corresponding to mucinous cysts. Viscosity measured at a high shear rate was shown to serve as an accurate and independent marker distinguishing between mucinous and non-mucinous cysts, with an optimal cutoff value of ηc = 1.3 cP The accuracy of this novel technique proved superior to string-sign, cytology, carcinoembryonic antigen, and amylase assessments. Moreover, the combined predictive value of ηc and patient age provided for sensitivity and specificity of 100% and 95.5%, respectively. This simple and rapid diagnostic tool can be immediately implemented after EUS-FNA sampling.
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Affiliation(s)
- Iyad Khamaysi
- Department of Gastroenterology, Bruce Rappaport Sch Med, Technion IIT, Haifa 32000, Israel
- Gastroenterology department, Rambam Health Care Campus, Haifa 31096, Israel
| | - Aiman Abu Ammar
- NanoEngineering Group, Faculty of Mechanical Engineering, Technion – IIT, Haifa 32000, Israel
| | - Gleb Vasilyev
- NanoEngineering Group, Faculty of Mechanical Engineering, Technion – IIT, Haifa 32000, Israel
| | - Arkadii Arinstein
- NanoEngineering Group, Faculty of Mechanical Engineering, Technion – IIT, Haifa 32000, Israel
| | - Yehuda Chowers
- Department of Gastroenterology, Bruce Rappaport Sch Med, Technion IIT, Haifa 32000, Israel
- Gastroenterology department, Rambam Health Care Campus, Haifa 31096, Israel
| | - Eyal Zussman
- NanoEngineering Group, Faculty of Mechanical Engineering, Technion – IIT, Haifa 32000, Israel
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41
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Singh P, Blatt A, Feld S, Zohar Y, Saadi E, Barki-Harrington L, Hammond E, Ilan N, Vlodavsky I, Chowers Y, Half E. The Heparanase Inhibitor PG545 Attenuates Colon Cancer Initiation and Growth, Associating with Increased p21 Expression. Neoplasia 2017; 19:175-184. [PMID: 28147305 PMCID: PMC5279702 DOI: 10.1016/j.neo.2016.12.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 12/01/2016] [Accepted: 12/05/2016] [Indexed: 01/07/2023] Open
Abstract
Heparanase activity is highly implicated in cellular invasion and tumor metastasis, a consequence of cleavage of heparan sulfate and remodeling of the extracellular matrix underlying epithelial and endothelial cells. Heparanase expression is rare in normal epithelia, but is often induced in tumors, associated with increased tumor metastasis and poor prognosis. In addition, heparanase induction promotes tumor growth, but the molecular mechanism that underlines tumor expansion by heparanase is still incompletely understood. Here, we provide evidence that heparanase down regulates the expression of p21 (WAF1/CIP1), a cyclin-dependent kinase inhibitor that attenuates the cell cycle. Notably, a reciprocal effect was noted for PG545, a potent heparanase inhibitor. This compound efficiently reduced cell proliferation, colony formation, and tumor xenograft growth, associating with a marked increase in p21 expression. Utilizing the APC Min+/− mouse model, we show that heparanase expression and activity are increased in small bowel polyps, whereas polyp initiation and growth were significantly inhibited by PG545, again accompanied by a prominent induction of p21 levels. Down-regulation of p21 expression adds a novel feature for the emerging pro-tumorigenic properties of heparanase, while the potent p21 induction and anti-tumor effect of PG545 lends optimism that it would prove an efficacious therapeutic in colon carcinoma patients.
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Affiliation(s)
- Preeti Singh
- Cancer and Vascular Biology Research Center, the Bruce Rappaport Faculty of Medicine, Technion, Haifa 31096, Israel
| | - Alexandra Blatt
- Department of Gastroenterology, Rambam Health Care Campus and Bruce Rappaport School of Medicine, Technion, Haifa 3109601, Israel
| | - Sari Feld
- Cancer and Vascular Biology Research Center, the Bruce Rappaport Faculty of Medicine, Technion, Haifa 31096, Israel
| | - Yaniv Zohar
- Department of Pathology, Rambam Health Care Campus and Bruce Rappaport School of Medicine, Technion, Haifa 3109601, Israel
| | - Esraa Saadi
- Department of Human Biology, University of Haifa, Haifa 31905, Israel
| | | | | | - Neta Ilan
- Cancer and Vascular Biology Research Center, the Bruce Rappaport Faculty of Medicine, Technion, Haifa 31096, Israel
| | - Israel Vlodavsky
- Cancer and Vascular Biology Research Center, the Bruce Rappaport Faculty of Medicine, Technion, Haifa 31096, Israel
| | - Yehuda Chowers
- Department of Gastroenterology, Rambam Health Care Campus and Bruce Rappaport School of Medicine, Technion, Haifa 3109601, Israel.
| | - Elizabeth Half
- Department of Gastroenterology, Rambam Health Care Campus and Bruce Rappaport School of Medicine, Technion, Haifa 3109601, Israel.
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42
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Bar-Yoseph H, Waterman M, Almog R, Billiet T, Vermeire S, Ungar B, Yanai H, Dotan I, Ben-Horin S, Chowers Y. Prevention of Antidrug Antibody Formation to Infliximab in Crohn's Patients With Prior Failure of Thiopurines. Clin Gastroenterol Hepatol 2017; 15:69-75. [PMID: 27404966 DOI: 10.1016/j.cgh.2016.06.028] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 06/21/2016] [Accepted: 06/21/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Combination thiopurine-infliximab (IFX) therapy is associated with reduced generation of antidrug antibodies (ADA) compared with IFX monotherapy. Whether past clinical response to thiopurine therapy bears an effect on ADA prevention is unknown. METHODS This was a retrospective observational multicenter study of patients with Crohn's disease (CD) treated by IFX and thiopurines who had serial ADA measurements. Therapy was classified into past thiopurine response or its lack of, de novo combination, or IFX monotherapy. The primary endpoint was risk of ADA appearance. RESULTS Out of 494 patients with serial ADA measurements 207 eligible patients were included in the final analysis. The 1-year cumulative risk of ADA development was similar in past thiopurine responders (19.3%) compared with past thiopurine failures (16.1%) (log rank P = .54). ADA was found in 46.6% of the monotherapy group and was significantly different compared with past thiopurine responders (P = .007) and past thiopurine failures (P = .007). The adjusted hazards for ADA development were significantly lower in past responders and past failures compared with the monotherapy group (hazard ratio, 0.47 [95% CI, 0.22-1.00] and 0.32 [95% CI, 0.11-0.93], respectively). CONCLUSIONS Thiopurines-IFX cotherapy in patients with Crohn's disease is associated with reduced ADA formation compared with IFX monotherapy. This is probably regardless of initial thiopurine therapeutic effect.
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Affiliation(s)
- Haggai Bar-Yoseph
- Department of Internal Medicine H, Rambam Health Care Campus and Bruce Rappaport School of Medicine, Technion Israel Institute of Technology, Haifa, Israel.
| | - Matti Waterman
- Department of Gastroenterology, Rambam Health Care Campus and Bruce Rappaport School of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Ronit Almog
- Department of Epidemiology, Rambam Health Care Campus and School of Public Health, University of Haifa, Haifa, Israel
| | - Thomas Billiet
- Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium
| | - Séverine Vermeire
- Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium
| | - Bella Ungar
- Department of Gastroenterology, Chaim Sheba Medical Center, Ramat-gan and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Henit Yanai
- IBD Center, Department of Gastroenterology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Iris Dotan
- IBD Center, Department of Gastroenterology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shomron Ben-Horin
- Department of Gastroenterology, Chaim Sheba Medical Center, Ramat-gan and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yehuda Chowers
- Department of Gastroenterology, Rambam Health Care Campus and Bruce Rappaport School of Medicine, Technion Israel Institute of Technology, Haifa, Israel
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Gomollón F, Dignass A, Annese V, Tilg H, Van Assche G, Lindsay JO, Peyrin-Biroulet L, Cullen GJ, Daperno M, Kucharzik T, Rieder F, Almer S, Armuzzi A, Harbord M, Langhorst J, Sans M, Chowers Y, Fiorino G, Juillerat P, Mantzaris GJ, Rizzello F, Vavricka S, Gionchetti P. 3rd European Evidence-based Consensus on the Diagnosis and Management of Crohn's Disease 2016: Part 1: Diagnosis and Medical Management. J Crohns Colitis 2017; 11:3-25. [PMID: 27660341 DOI: 10.1093/ecco-jcc/jjw168] [Citation(s) in RCA: 1282] [Impact Index Per Article: 183.1] [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: 09/01/2016] [Revised: 09/20/2016] [Accepted: 09/21/2016] [Indexed: 02/08/2023]
Abstract
This paper is the first in a series of two publications relating to the European Crohn's and Colitis Organisation [ECCO] evidence-based consensus on the diagnosis and management of Crohn's disease and concerns the methodology of the consensus process, and the classification, diagnosis and medical management of active and quiescent Crohn's disease. Surgical management as well as special situations including management of perianal Crohn's disease of this ECCO Consensus are covered in a subsequent second paper [Gionchetti et al JCC 2016].
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Affiliation(s)
- Fernando Gomollón
- Fernando Gomollón, Professor of Medicine, Hospital Clínico Universitario "Lozano Blesa", Universidad de Zaragoza, IIS Aragón, CIBEREHD, Zaragoza, Spain.,Axel Dignass, Department of Medicine I, Agaplesion Markus Hospital, Willhelm-Epstein-Straße 4, 60431 Frankfurt/Main, Germany.,Vito Annese, Department of Emergency, Division of Gastroenterology, University Hospital Careggi, Largo Giovanni Alessandro Brambilla, 3, 50134 Florence, Italy.,Herbert Tilg, Department of Internal Medicine I, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.,Gert Van Assche, Division of Gastroenterology and Hepatology, University Hospitals Leuven and University of Leuven, 49 Herestraat, 3000 Leuven, Belgium.,James O. Lindsay, Department of Gastroenterology, Barts Health NHS Trust, The Royal London Hospital, Whitechapel Road, London E1 1BB, UK.,Laurent Peyrin-Biroulet, Department of Gastroenterology and Inserm U954, Nancy University Hospital, Lorraine University, 54500 Vandoeuvre-Lès-Nancy, France.,Garret J. Cullen, Department of Gastroenterology, Centre for Colorectal Disease, St. Vincent's University Hospital, 4 Dublin, Ireland.,Marco Daperno, Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, 10128 Torino, Italy.,Torsten Kucharzik, Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Bögelstraße 1, 21339 Lüneburg, Germany.,Florian Rieder, Department of Pathobiology/NC22, Lerner Research Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA; Department of Gastroenterology, Hepatology and Nutrition/A3, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA.,Sven Almer, Department of Medicine, Solna, Karolinska Institute, and, IBD-unit, Center for Digestive Diseases, Karolinska University Hospital, 17176 Stockholm, Sweden.,Alessandro Armuzzi, Department of Internal Medicine, IBD Unit Complesso Integrato Columbus, Gemelli Hospital Catholic University Foundation, Via Giuseppe Moscati 31, 00168 Rome, Italy.,Marcus Harbord, Imperial College, London; and Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK.,Jost Langhorst, Department of Internal Medicine and Integrative Gastroenterology, University Duisburg-Essen, Kliniken Essen-Mitte, Am Deimelsberg 34A, 45276 Essen, Germany.,Miquel Sans, Department of Digestive Diseases, Centro Médico Teknon, 12 Vilana, 08009 Barcelona, Spain.,Yehuda Chowers, Department of Gastroenterology, Rambam Health Care Campus Rappaport Faculty Of Medicine, 8 Ha'Aliya Street, PO Box 9602, 3109601 Haifa, Israel.,Gionata Fiorino, IRCCS Humanitas Research Hospital, Department of Gastroenterology, IBD Center, Via Manzoni, 56, 20089 Rozzano, Italy.,Pascal Juillerat, Department of Gastroenterology, University Clinic for Visceral Surgery and Medicine, University Hospital Bern Inselspital, Freiburgstrasse 10, 3010 Bern, Switzerland.,Gerassimos J. Mantzaris , Department of Gastroenterology, Evangelismos Hospital, 45-47 Ypsilandou Street, 10676 Athens, Greece.,Fernando Rizzello, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy.,Paolo Gionchetti, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy
| | - Axel Dignass
- Fernando Gomollón, Professor of Medicine, Hospital Clínico Universitario "Lozano Blesa", Universidad de Zaragoza, IIS Aragón, CIBEREHD, Zaragoza, Spain.,Axel Dignass, Department of Medicine I, Agaplesion Markus Hospital, Willhelm-Epstein-Straße 4, 60431 Frankfurt/Main, Germany.,Vito Annese, Department of Emergency, Division of Gastroenterology, University Hospital Careggi, Largo Giovanni Alessandro Brambilla, 3, 50134 Florence, Italy.,Herbert Tilg, Department of Internal Medicine I, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.,Gert Van Assche, Division of Gastroenterology and Hepatology, University Hospitals Leuven and University of Leuven, 49 Herestraat, 3000 Leuven, Belgium.,James O. Lindsay, Department of Gastroenterology, Barts Health NHS Trust, The Royal London Hospital, Whitechapel Road, London E1 1BB, UK.,Laurent Peyrin-Biroulet, Department of Gastroenterology and Inserm U954, Nancy University Hospital, Lorraine University, 54500 Vandoeuvre-Lès-Nancy, France.,Garret J. Cullen, Department of Gastroenterology, Centre for Colorectal Disease, St. Vincent's University Hospital, 4 Dublin, Ireland.,Marco Daperno, Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, 10128 Torino, Italy.,Torsten Kucharzik, Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Bögelstraße 1, 21339 Lüneburg, Germany.,Florian Rieder, Department of Pathobiology/NC22, Lerner Research Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA; Department of Gastroenterology, Hepatology and Nutrition/A3, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA.,Sven Almer, Department of Medicine, Solna, Karolinska Institute, and, IBD-unit, Center for Digestive Diseases, Karolinska University Hospital, 17176 Stockholm, Sweden.,Alessandro Armuzzi, Department of Internal Medicine, IBD Unit Complesso Integrato Columbus, Gemelli Hospital Catholic University Foundation, Via Giuseppe Moscati 31, 00168 Rome, Italy.,Marcus Harbord, Imperial College, London; and Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK.,Jost Langhorst, Department of Internal Medicine and Integrative Gastroenterology, University Duisburg-Essen, Kliniken Essen-Mitte, Am Deimelsberg 34A, 45276 Essen, Germany.,Miquel Sans, Department of Digestive Diseases, Centro Médico Teknon, 12 Vilana, 08009 Barcelona, Spain.,Yehuda Chowers, Department of Gastroenterology, Rambam Health Care Campus Rappaport Faculty Of Medicine, 8 Ha'Aliya Street, PO Box 9602, 3109601 Haifa, Israel.,Gionata Fiorino, IRCCS Humanitas Research Hospital, Department of Gastroenterology, IBD Center, Via Manzoni, 56, 20089 Rozzano, Italy.,Pascal Juillerat, Department of Gastroenterology, University Clinic for Visceral Surgery and Medicine, University Hospital Bern Inselspital, Freiburgstrasse 10, 3010 Bern, Switzerland.,Gerassimos J. Mantzaris , Department of Gastroenterology, Evangelismos Hospital, 45-47 Ypsilandou Street, 10676 Athens, Greece.,Fernando Rizzello, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy.,Paolo Gionchetti, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy
| | - Vito Annese
- Fernando Gomollón, Professor of Medicine, Hospital Clínico Universitario "Lozano Blesa", Universidad de Zaragoza, IIS Aragón, CIBEREHD, Zaragoza, Spain.,Axel Dignass, Department of Medicine I, Agaplesion Markus Hospital, Willhelm-Epstein-Straße 4, 60431 Frankfurt/Main, Germany.,Vito Annese, Department of Emergency, Division of Gastroenterology, University Hospital Careggi, Largo Giovanni Alessandro Brambilla, 3, 50134 Florence, Italy.,Herbert Tilg, Department of Internal Medicine I, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.,Gert Van Assche, Division of Gastroenterology and Hepatology, University Hospitals Leuven and University of Leuven, 49 Herestraat, 3000 Leuven, Belgium.,James O. Lindsay, Department of Gastroenterology, Barts Health NHS Trust, The Royal London Hospital, Whitechapel Road, London E1 1BB, UK.,Laurent Peyrin-Biroulet, Department of Gastroenterology and Inserm U954, Nancy University Hospital, Lorraine University, 54500 Vandoeuvre-Lès-Nancy, France.,Garret J. Cullen, Department of Gastroenterology, Centre for Colorectal Disease, St. Vincent's University Hospital, 4 Dublin, Ireland.,Marco Daperno, Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, 10128 Torino, Italy.,Torsten Kucharzik, Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Bögelstraße 1, 21339 Lüneburg, Germany.,Florian Rieder, Department of Pathobiology/NC22, Lerner Research Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA; Department of Gastroenterology, Hepatology and Nutrition/A3, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA.,Sven Almer, Department of Medicine, Solna, Karolinska Institute, and, IBD-unit, Center for Digestive Diseases, Karolinska University Hospital, 17176 Stockholm, Sweden.,Alessandro Armuzzi, Department of Internal Medicine, IBD Unit Complesso Integrato Columbus, Gemelli Hospital Catholic University Foundation, Via Giuseppe Moscati 31, 00168 Rome, Italy.,Marcus Harbord, Imperial College, London; and Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK.,Jost Langhorst, Department of Internal Medicine and Integrative Gastroenterology, University Duisburg-Essen, Kliniken Essen-Mitte, Am Deimelsberg 34A, 45276 Essen, Germany.,Miquel Sans, Department of Digestive Diseases, Centro Médico Teknon, 12 Vilana, 08009 Barcelona, Spain.,Yehuda Chowers, Department of Gastroenterology, Rambam Health Care Campus Rappaport Faculty Of Medicine, 8 Ha'Aliya Street, PO Box 9602, 3109601 Haifa, Israel.,Gionata Fiorino, IRCCS Humanitas Research Hospital, Department of Gastroenterology, IBD Center, Via Manzoni, 56, 20089 Rozzano, Italy.,Pascal Juillerat, Department of Gastroenterology, University Clinic for Visceral Surgery and Medicine, University Hospital Bern Inselspital, Freiburgstrasse 10, 3010 Bern, Switzerland.,Gerassimos J. Mantzaris , Department of Gastroenterology, Evangelismos Hospital, 45-47 Ypsilandou Street, 10676 Athens, Greece.,Fernando Rizzello, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy.,Paolo Gionchetti, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy
| | - Herbert Tilg
- Fernando Gomollón, Professor of Medicine, Hospital Clínico Universitario "Lozano Blesa", Universidad de Zaragoza, IIS Aragón, CIBEREHD, Zaragoza, Spain.,Axel Dignass, Department of Medicine I, Agaplesion Markus Hospital, Willhelm-Epstein-Straße 4, 60431 Frankfurt/Main, Germany.,Vito Annese, Department of Emergency, Division of Gastroenterology, University Hospital Careggi, Largo Giovanni Alessandro Brambilla, 3, 50134 Florence, Italy.,Herbert Tilg, Department of Internal Medicine I, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.,Gert Van Assche, Division of Gastroenterology and Hepatology, University Hospitals Leuven and University of Leuven, 49 Herestraat, 3000 Leuven, Belgium.,James O. Lindsay, Department of Gastroenterology, Barts Health NHS Trust, The Royal London Hospital, Whitechapel Road, London E1 1BB, UK.,Laurent Peyrin-Biroulet, Department of Gastroenterology and Inserm U954, Nancy University Hospital, Lorraine University, 54500 Vandoeuvre-Lès-Nancy, France.,Garret J. Cullen, Department of Gastroenterology, Centre for Colorectal Disease, St. Vincent's University Hospital, 4 Dublin, Ireland.,Marco Daperno, Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, 10128 Torino, Italy.,Torsten Kucharzik, Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Bögelstraße 1, 21339 Lüneburg, Germany.,Florian Rieder, Department of Pathobiology/NC22, Lerner Research Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA; Department of Gastroenterology, Hepatology and Nutrition/A3, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA.,Sven Almer, Department of Medicine, Solna, Karolinska Institute, and, IBD-unit, Center for Digestive Diseases, Karolinska University Hospital, 17176 Stockholm, Sweden.,Alessandro Armuzzi, Department of Internal Medicine, IBD Unit Complesso Integrato Columbus, Gemelli Hospital Catholic University Foundation, Via Giuseppe Moscati 31, 00168 Rome, Italy.,Marcus Harbord, Imperial College, London; and Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK.,Jost Langhorst, Department of Internal Medicine and Integrative Gastroenterology, University Duisburg-Essen, Kliniken Essen-Mitte, Am Deimelsberg 34A, 45276 Essen, Germany.,Miquel Sans, Department of Digestive Diseases, Centro Médico Teknon, 12 Vilana, 08009 Barcelona, Spain.,Yehuda Chowers, Department of Gastroenterology, Rambam Health Care Campus Rappaport Faculty Of Medicine, 8 Ha'Aliya Street, PO Box 9602, 3109601 Haifa, Israel.,Gionata Fiorino, IRCCS Humanitas Research Hospital, Department of Gastroenterology, IBD Center, Via Manzoni, 56, 20089 Rozzano, Italy.,Pascal Juillerat, Department of Gastroenterology, University Clinic for Visceral Surgery and Medicine, University Hospital Bern Inselspital, Freiburgstrasse 10, 3010 Bern, Switzerland.,Gerassimos J. Mantzaris , Department of Gastroenterology, Evangelismos Hospital, 45-47 Ypsilandou Street, 10676 Athens, Greece.,Fernando Rizzello, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy.,Paolo Gionchetti, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy
| | - Gert Van Assche
- Fernando Gomollón, Professor of Medicine, Hospital Clínico Universitario "Lozano Blesa", Universidad de Zaragoza, IIS Aragón, CIBEREHD, Zaragoza, Spain.,Axel Dignass, Department of Medicine I, Agaplesion Markus Hospital, Willhelm-Epstein-Straße 4, 60431 Frankfurt/Main, Germany.,Vito Annese, Department of Emergency, Division of Gastroenterology, University Hospital Careggi, Largo Giovanni Alessandro Brambilla, 3, 50134 Florence, Italy.,Herbert Tilg, Department of Internal Medicine I, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.,Gert Van Assche, Division of Gastroenterology and Hepatology, University Hospitals Leuven and University of Leuven, 49 Herestraat, 3000 Leuven, Belgium.,James O. Lindsay, Department of Gastroenterology, Barts Health NHS Trust, The Royal London Hospital, Whitechapel Road, London E1 1BB, UK.,Laurent Peyrin-Biroulet, Department of Gastroenterology and Inserm U954, Nancy University Hospital, Lorraine University, 54500 Vandoeuvre-Lès-Nancy, France.,Garret J. Cullen, Department of Gastroenterology, Centre for Colorectal Disease, St. Vincent's University Hospital, 4 Dublin, Ireland.,Marco Daperno, Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, 10128 Torino, Italy.,Torsten Kucharzik, Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Bögelstraße 1, 21339 Lüneburg, Germany.,Florian Rieder, Department of Pathobiology/NC22, Lerner Research Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA; Department of Gastroenterology, Hepatology and Nutrition/A3, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA.,Sven Almer, Department of Medicine, Solna, Karolinska Institute, and, IBD-unit, Center for Digestive Diseases, Karolinska University Hospital, 17176 Stockholm, Sweden.,Alessandro Armuzzi, Department of Internal Medicine, IBD Unit Complesso Integrato Columbus, Gemelli Hospital Catholic University Foundation, Via Giuseppe Moscati 31, 00168 Rome, Italy.,Marcus Harbord, Imperial College, London; and Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK.,Jost Langhorst, Department of Internal Medicine and Integrative Gastroenterology, University Duisburg-Essen, Kliniken Essen-Mitte, Am Deimelsberg 34A, 45276 Essen, Germany.,Miquel Sans, Department of Digestive Diseases, Centro Médico Teknon, 12 Vilana, 08009 Barcelona, Spain.,Yehuda Chowers, Department of Gastroenterology, Rambam Health Care Campus Rappaport Faculty Of Medicine, 8 Ha'Aliya Street, PO Box 9602, 3109601 Haifa, Israel.,Gionata Fiorino, IRCCS Humanitas Research Hospital, Department of Gastroenterology, IBD Center, Via Manzoni, 56, 20089 Rozzano, Italy.,Pascal Juillerat, Department of Gastroenterology, University Clinic for Visceral Surgery and Medicine, University Hospital Bern Inselspital, Freiburgstrasse 10, 3010 Bern, Switzerland.,Gerassimos J. Mantzaris , Department of Gastroenterology, Evangelismos Hospital, 45-47 Ypsilandou Street, 10676 Athens, Greece.,Fernando Rizzello, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy.,Paolo Gionchetti, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy
| | - James O Lindsay
- Fernando Gomollón, Professor of Medicine, Hospital Clínico Universitario "Lozano Blesa", Universidad de Zaragoza, IIS Aragón, CIBEREHD, Zaragoza, Spain.,Axel Dignass, Department of Medicine I, Agaplesion Markus Hospital, Willhelm-Epstein-Straße 4, 60431 Frankfurt/Main, Germany.,Vito Annese, Department of Emergency, Division of Gastroenterology, University Hospital Careggi, Largo Giovanni Alessandro Brambilla, 3, 50134 Florence, Italy.,Herbert Tilg, Department of Internal Medicine I, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.,Gert Van Assche, Division of Gastroenterology and Hepatology, University Hospitals Leuven and University of Leuven, 49 Herestraat, 3000 Leuven, Belgium.,James O. Lindsay, Department of Gastroenterology, Barts Health NHS Trust, The Royal London Hospital, Whitechapel Road, London E1 1BB, UK.,Laurent Peyrin-Biroulet, Department of Gastroenterology and Inserm U954, Nancy University Hospital, Lorraine University, 54500 Vandoeuvre-Lès-Nancy, France.,Garret J. Cullen, Department of Gastroenterology, Centre for Colorectal Disease, St. Vincent's University Hospital, 4 Dublin, Ireland.,Marco Daperno, Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, 10128 Torino, Italy.,Torsten Kucharzik, Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Bögelstraße 1, 21339 Lüneburg, Germany.,Florian Rieder, Department of Pathobiology/NC22, Lerner Research Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA; Department of Gastroenterology, Hepatology and Nutrition/A3, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA.,Sven Almer, Department of Medicine, Solna, Karolinska Institute, and, IBD-unit, Center for Digestive Diseases, Karolinska University Hospital, 17176 Stockholm, Sweden.,Alessandro Armuzzi, Department of Internal Medicine, IBD Unit Complesso Integrato Columbus, Gemelli Hospital Catholic University Foundation, Via Giuseppe Moscati 31, 00168 Rome, Italy.,Marcus Harbord, Imperial College, London; and Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK.,Jost Langhorst, Department of Internal Medicine and Integrative Gastroenterology, University Duisburg-Essen, Kliniken Essen-Mitte, Am Deimelsberg 34A, 45276 Essen, Germany.,Miquel Sans, Department of Digestive Diseases, Centro Médico Teknon, 12 Vilana, 08009 Barcelona, Spain.,Yehuda Chowers, Department of Gastroenterology, Rambam Health Care Campus Rappaport Faculty Of Medicine, 8 Ha'Aliya Street, PO Box 9602, 3109601 Haifa, Israel.,Gionata Fiorino, IRCCS Humanitas Research Hospital, Department of Gastroenterology, IBD Center, Via Manzoni, 56, 20089 Rozzano, Italy.,Pascal Juillerat, Department of Gastroenterology, University Clinic for Visceral Surgery and Medicine, University Hospital Bern Inselspital, Freiburgstrasse 10, 3010 Bern, Switzerland.,Gerassimos J. Mantzaris , Department of Gastroenterology, Evangelismos Hospital, 45-47 Ypsilandou Street, 10676 Athens, Greece.,Fernando Rizzello, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy.,Paolo Gionchetti, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy
| | - Laurent Peyrin-Biroulet
- Fernando Gomollón, Professor of Medicine, Hospital Clínico Universitario "Lozano Blesa", Universidad de Zaragoza, IIS Aragón, CIBEREHD, Zaragoza, Spain.,Axel Dignass, Department of Medicine I, Agaplesion Markus Hospital, Willhelm-Epstein-Straße 4, 60431 Frankfurt/Main, Germany.,Vito Annese, Department of Emergency, Division of Gastroenterology, University Hospital Careggi, Largo Giovanni Alessandro Brambilla, 3, 50134 Florence, Italy.,Herbert Tilg, Department of Internal Medicine I, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.,Gert Van Assche, Division of Gastroenterology and Hepatology, University Hospitals Leuven and University of Leuven, 49 Herestraat, 3000 Leuven, Belgium.,James O. Lindsay, Department of Gastroenterology, Barts Health NHS Trust, The Royal London Hospital, Whitechapel Road, London E1 1BB, UK.,Laurent Peyrin-Biroulet, Department of Gastroenterology and Inserm U954, Nancy University Hospital, Lorraine University, 54500 Vandoeuvre-Lès-Nancy, France.,Garret J. Cullen, Department of Gastroenterology, Centre for Colorectal Disease, St. Vincent's University Hospital, 4 Dublin, Ireland.,Marco Daperno, Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, 10128 Torino, Italy.,Torsten Kucharzik, Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Bögelstraße 1, 21339 Lüneburg, Germany.,Florian Rieder, Department of Pathobiology/NC22, Lerner Research Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA; Department of Gastroenterology, Hepatology and Nutrition/A3, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA.,Sven Almer, Department of Medicine, Solna, Karolinska Institute, and, IBD-unit, Center for Digestive Diseases, Karolinska University Hospital, 17176 Stockholm, Sweden.,Alessandro Armuzzi, Department of Internal Medicine, IBD Unit Complesso Integrato Columbus, Gemelli Hospital Catholic University Foundation, Via Giuseppe Moscati 31, 00168 Rome, Italy.,Marcus Harbord, Imperial College, London; and Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK.,Jost Langhorst, Department of Internal Medicine and Integrative Gastroenterology, University Duisburg-Essen, Kliniken Essen-Mitte, Am Deimelsberg 34A, 45276 Essen, Germany.,Miquel Sans, Department of Digestive Diseases, Centro Médico Teknon, 12 Vilana, 08009 Barcelona, Spain.,Yehuda Chowers, Department of Gastroenterology, Rambam Health Care Campus Rappaport Faculty Of Medicine, 8 Ha'Aliya Street, PO Box 9602, 3109601 Haifa, Israel.,Gionata Fiorino, IRCCS Humanitas Research Hospital, Department of Gastroenterology, IBD Center, Via Manzoni, 56, 20089 Rozzano, Italy.,Pascal Juillerat, Department of Gastroenterology, University Clinic for Visceral Surgery and Medicine, University Hospital Bern Inselspital, Freiburgstrasse 10, 3010 Bern, Switzerland.,Gerassimos J. Mantzaris , Department of Gastroenterology, Evangelismos Hospital, 45-47 Ypsilandou Street, 10676 Athens, Greece.,Fernando Rizzello, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy.,Paolo Gionchetti, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy
| | - Garret J Cullen
- Fernando Gomollón, Professor of Medicine, Hospital Clínico Universitario "Lozano Blesa", Universidad de Zaragoza, IIS Aragón, CIBEREHD, Zaragoza, Spain.,Axel Dignass, Department of Medicine I, Agaplesion Markus Hospital, Willhelm-Epstein-Straße 4, 60431 Frankfurt/Main, Germany.,Vito Annese, Department of Emergency, Division of Gastroenterology, University Hospital Careggi, Largo Giovanni Alessandro Brambilla, 3, 50134 Florence, Italy.,Herbert Tilg, Department of Internal Medicine I, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.,Gert Van Assche, Division of Gastroenterology and Hepatology, University Hospitals Leuven and University of Leuven, 49 Herestraat, 3000 Leuven, Belgium.,James O. Lindsay, Department of Gastroenterology, Barts Health NHS Trust, The Royal London Hospital, Whitechapel Road, London E1 1BB, UK.,Laurent Peyrin-Biroulet, Department of Gastroenterology and Inserm U954, Nancy University Hospital, Lorraine University, 54500 Vandoeuvre-Lès-Nancy, France.,Garret J. Cullen, Department of Gastroenterology, Centre for Colorectal Disease, St. Vincent's University Hospital, 4 Dublin, Ireland.,Marco Daperno, Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, 10128 Torino, Italy.,Torsten Kucharzik, Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Bögelstraße 1, 21339 Lüneburg, Germany.,Florian Rieder, Department of Pathobiology/NC22, Lerner Research Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA; Department of Gastroenterology, Hepatology and Nutrition/A3, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA.,Sven Almer, Department of Medicine, Solna, Karolinska Institute, and, IBD-unit, Center for Digestive Diseases, Karolinska University Hospital, 17176 Stockholm, Sweden.,Alessandro Armuzzi, Department of Internal Medicine, IBD Unit Complesso Integrato Columbus, Gemelli Hospital Catholic University Foundation, Via Giuseppe Moscati 31, 00168 Rome, Italy.,Marcus Harbord, Imperial College, London; and Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK.,Jost Langhorst, Department of Internal Medicine and Integrative Gastroenterology, University Duisburg-Essen, Kliniken Essen-Mitte, Am Deimelsberg 34A, 45276 Essen, Germany.,Miquel Sans, Department of Digestive Diseases, Centro Médico Teknon, 12 Vilana, 08009 Barcelona, Spain.,Yehuda Chowers, Department of Gastroenterology, Rambam Health Care Campus Rappaport Faculty Of Medicine, 8 Ha'Aliya Street, PO Box 9602, 3109601 Haifa, Israel.,Gionata Fiorino, IRCCS Humanitas Research Hospital, Department of Gastroenterology, IBD Center, Via Manzoni, 56, 20089 Rozzano, Italy.,Pascal Juillerat, Department of Gastroenterology, University Clinic for Visceral Surgery and Medicine, University Hospital Bern Inselspital, Freiburgstrasse 10, 3010 Bern, Switzerland.,Gerassimos J. Mantzaris , Department of Gastroenterology, Evangelismos Hospital, 45-47 Ypsilandou Street, 10676 Athens, Greece.,Fernando Rizzello, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy.,Paolo Gionchetti, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy
| | - Marco Daperno
- Fernando Gomollón, Professor of Medicine, Hospital Clínico Universitario "Lozano Blesa", Universidad de Zaragoza, IIS Aragón, CIBEREHD, Zaragoza, Spain.,Axel Dignass, Department of Medicine I, Agaplesion Markus Hospital, Willhelm-Epstein-Straße 4, 60431 Frankfurt/Main, Germany.,Vito Annese, Department of Emergency, Division of Gastroenterology, University Hospital Careggi, Largo Giovanni Alessandro Brambilla, 3, 50134 Florence, Italy.,Herbert Tilg, Department of Internal Medicine I, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.,Gert Van Assche, Division of Gastroenterology and Hepatology, University Hospitals Leuven and University of Leuven, 49 Herestraat, 3000 Leuven, Belgium.,James O. Lindsay, Department of Gastroenterology, Barts Health NHS Trust, The Royal London Hospital, Whitechapel Road, London E1 1BB, UK.,Laurent Peyrin-Biroulet, Department of Gastroenterology and Inserm U954, Nancy University Hospital, Lorraine University, 54500 Vandoeuvre-Lès-Nancy, France.,Garret J. Cullen, Department of Gastroenterology, Centre for Colorectal Disease, St. Vincent's University Hospital, 4 Dublin, Ireland.,Marco Daperno, Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, 10128 Torino, Italy.,Torsten Kucharzik, Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Bögelstraße 1, 21339 Lüneburg, Germany.,Florian Rieder, Department of Pathobiology/NC22, Lerner Research Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA; Department of Gastroenterology, Hepatology and Nutrition/A3, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA.,Sven Almer, Department of Medicine, Solna, Karolinska Institute, and, IBD-unit, Center for Digestive Diseases, Karolinska University Hospital, 17176 Stockholm, Sweden.,Alessandro Armuzzi, Department of Internal Medicine, IBD Unit Complesso Integrato Columbus, Gemelli Hospital Catholic University Foundation, Via Giuseppe Moscati 31, 00168 Rome, Italy.,Marcus Harbord, Imperial College, London; and Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK.,Jost Langhorst, Department of Internal Medicine and Integrative Gastroenterology, University Duisburg-Essen, Kliniken Essen-Mitte, Am Deimelsberg 34A, 45276 Essen, Germany.,Miquel Sans, Department of Digestive Diseases, Centro Médico Teknon, 12 Vilana, 08009 Barcelona, Spain.,Yehuda Chowers, Department of Gastroenterology, Rambam Health Care Campus Rappaport Faculty Of Medicine, 8 Ha'Aliya Street, PO Box 9602, 3109601 Haifa, Israel.,Gionata Fiorino, IRCCS Humanitas Research Hospital, Department of Gastroenterology, IBD Center, Via Manzoni, 56, 20089 Rozzano, Italy.,Pascal Juillerat, Department of Gastroenterology, University Clinic for Visceral Surgery and Medicine, University Hospital Bern Inselspital, Freiburgstrasse 10, 3010 Bern, Switzerland.,Gerassimos J. Mantzaris , Department of Gastroenterology, Evangelismos Hospital, 45-47 Ypsilandou Street, 10676 Athens, Greece.,Fernando Rizzello, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy.,Paolo Gionchetti, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy
| | - Torsten Kucharzik
- Fernando Gomollón, Professor of Medicine, Hospital Clínico Universitario "Lozano Blesa", Universidad de Zaragoza, IIS Aragón, CIBEREHD, Zaragoza, Spain.,Axel Dignass, Department of Medicine I, Agaplesion Markus Hospital, Willhelm-Epstein-Straße 4, 60431 Frankfurt/Main, Germany.,Vito Annese, Department of Emergency, Division of Gastroenterology, University Hospital Careggi, Largo Giovanni Alessandro Brambilla, 3, 50134 Florence, Italy.,Herbert Tilg, Department of Internal Medicine I, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.,Gert Van Assche, Division of Gastroenterology and Hepatology, University Hospitals Leuven and University of Leuven, 49 Herestraat, 3000 Leuven, Belgium.,James O. Lindsay, Department of Gastroenterology, Barts Health NHS Trust, The Royal London Hospital, Whitechapel Road, London E1 1BB, UK.,Laurent Peyrin-Biroulet, Department of Gastroenterology and Inserm U954, Nancy University Hospital, Lorraine University, 54500 Vandoeuvre-Lès-Nancy, France.,Garret J. Cullen, Department of Gastroenterology, Centre for Colorectal Disease, St. Vincent's University Hospital, 4 Dublin, Ireland.,Marco Daperno, Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, 10128 Torino, Italy.,Torsten Kucharzik, Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Bögelstraße 1, 21339 Lüneburg, Germany.,Florian Rieder, Department of Pathobiology/NC22, Lerner Research Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA; Department of Gastroenterology, Hepatology and Nutrition/A3, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA.,Sven Almer, Department of Medicine, Solna, Karolinska Institute, and, IBD-unit, Center for Digestive Diseases, Karolinska University Hospital, 17176 Stockholm, Sweden.,Alessandro Armuzzi, Department of Internal Medicine, IBD Unit Complesso Integrato Columbus, Gemelli Hospital Catholic University Foundation, Via Giuseppe Moscati 31, 00168 Rome, Italy.,Marcus Harbord, Imperial College, London; and Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK.,Jost Langhorst, Department of Internal Medicine and Integrative Gastroenterology, University Duisburg-Essen, Kliniken Essen-Mitte, Am Deimelsberg 34A, 45276 Essen, Germany.,Miquel Sans, Department of Digestive Diseases, Centro Médico Teknon, 12 Vilana, 08009 Barcelona, Spain.,Yehuda Chowers, Department of Gastroenterology, Rambam Health Care Campus Rappaport Faculty Of Medicine, 8 Ha'Aliya Street, PO Box 9602, 3109601 Haifa, Israel.,Gionata Fiorino, IRCCS Humanitas Research Hospital, Department of Gastroenterology, IBD Center, Via Manzoni, 56, 20089 Rozzano, Italy.,Pascal Juillerat, Department of Gastroenterology, University Clinic for Visceral Surgery and Medicine, University Hospital Bern Inselspital, Freiburgstrasse 10, 3010 Bern, Switzerland.,Gerassimos J. Mantzaris , Department of Gastroenterology, Evangelismos Hospital, 45-47 Ypsilandou Street, 10676 Athens, Greece.,Fernando Rizzello, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy.,Paolo Gionchetti, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy
| | - Florian Rieder
- Fernando Gomollón, Professor of Medicine, Hospital Clínico Universitario "Lozano Blesa", Universidad de Zaragoza, IIS Aragón, CIBEREHD, Zaragoza, Spain.,Axel Dignass, Department of Medicine I, Agaplesion Markus Hospital, Willhelm-Epstein-Straße 4, 60431 Frankfurt/Main, Germany.,Vito Annese, Department of Emergency, Division of Gastroenterology, University Hospital Careggi, Largo Giovanni Alessandro Brambilla, 3, 50134 Florence, Italy.,Herbert Tilg, Department of Internal Medicine I, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.,Gert Van Assche, Division of Gastroenterology and Hepatology, University Hospitals Leuven and University of Leuven, 49 Herestraat, 3000 Leuven, Belgium.,James O. Lindsay, Department of Gastroenterology, Barts Health NHS Trust, The Royal London Hospital, Whitechapel Road, London E1 1BB, UK.,Laurent Peyrin-Biroulet, Department of Gastroenterology and Inserm U954, Nancy University Hospital, Lorraine University, 54500 Vandoeuvre-Lès-Nancy, France.,Garret J. Cullen, Department of Gastroenterology, Centre for Colorectal Disease, St. Vincent's University Hospital, 4 Dublin, Ireland.,Marco Daperno, Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, 10128 Torino, Italy.,Torsten Kucharzik, Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Bögelstraße 1, 21339 Lüneburg, Germany.,Florian Rieder, Department of Pathobiology/NC22, Lerner Research Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA; Department of Gastroenterology, Hepatology and Nutrition/A3, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA.,Sven Almer, Department of Medicine, Solna, Karolinska Institute, and, IBD-unit, Center for Digestive Diseases, Karolinska University Hospital, 17176 Stockholm, Sweden.,Alessandro Armuzzi, Department of Internal Medicine, IBD Unit Complesso Integrato Columbus, Gemelli Hospital Catholic University Foundation, Via Giuseppe Moscati 31, 00168 Rome, Italy.,Marcus Harbord, Imperial College, London; and Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK.,Jost Langhorst, Department of Internal Medicine and Integrative Gastroenterology, University Duisburg-Essen, Kliniken Essen-Mitte, Am Deimelsberg 34A, 45276 Essen, Germany.,Miquel Sans, Department of Digestive Diseases, Centro Médico Teknon, 12 Vilana, 08009 Barcelona, Spain.,Yehuda Chowers, Department of Gastroenterology, Rambam Health Care Campus Rappaport Faculty Of Medicine, 8 Ha'Aliya Street, PO Box 9602, 3109601 Haifa, Israel.,Gionata Fiorino, IRCCS Humanitas Research Hospital, Department of Gastroenterology, IBD Center, Via Manzoni, 56, 20089 Rozzano, Italy.,Pascal Juillerat, Department of Gastroenterology, University Clinic for Visceral Surgery and Medicine, University Hospital Bern Inselspital, Freiburgstrasse 10, 3010 Bern, Switzerland.,Gerassimos J. Mantzaris , Department of Gastroenterology, Evangelismos Hospital, 45-47 Ypsilandou Street, 10676 Athens, Greece.,Fernando Rizzello, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy.,Paolo Gionchetti, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy
| | - Sven Almer
- Fernando Gomollón, Professor of Medicine, Hospital Clínico Universitario "Lozano Blesa", Universidad de Zaragoza, IIS Aragón, CIBEREHD, Zaragoza, Spain.,Axel Dignass, Department of Medicine I, Agaplesion Markus Hospital, Willhelm-Epstein-Straße 4, 60431 Frankfurt/Main, Germany.,Vito Annese, Department of Emergency, Division of Gastroenterology, University Hospital Careggi, Largo Giovanni Alessandro Brambilla, 3, 50134 Florence, Italy.,Herbert Tilg, Department of Internal Medicine I, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.,Gert Van Assche, Division of Gastroenterology and Hepatology, University Hospitals Leuven and University of Leuven, 49 Herestraat, 3000 Leuven, Belgium.,James O. Lindsay, Department of Gastroenterology, Barts Health NHS Trust, The Royal London Hospital, Whitechapel Road, London E1 1BB, UK.,Laurent Peyrin-Biroulet, Department of Gastroenterology and Inserm U954, Nancy University Hospital, Lorraine University, 54500 Vandoeuvre-Lès-Nancy, France.,Garret J. Cullen, Department of Gastroenterology, Centre for Colorectal Disease, St. Vincent's University Hospital, 4 Dublin, Ireland.,Marco Daperno, Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, 10128 Torino, Italy.,Torsten Kucharzik, Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Bögelstraße 1, 21339 Lüneburg, Germany.,Florian Rieder, Department of Pathobiology/NC22, Lerner Research Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA; Department of Gastroenterology, Hepatology and Nutrition/A3, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA.,Sven Almer, Department of Medicine, Solna, Karolinska Institute, and, IBD-unit, Center for Digestive Diseases, Karolinska University Hospital, 17176 Stockholm, Sweden.,Alessandro Armuzzi, Department of Internal Medicine, IBD Unit Complesso Integrato Columbus, Gemelli Hospital Catholic University Foundation, Via Giuseppe Moscati 31, 00168 Rome, Italy.,Marcus Harbord, Imperial College, London; and Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK.,Jost Langhorst, Department of Internal Medicine and Integrative Gastroenterology, University Duisburg-Essen, Kliniken Essen-Mitte, Am Deimelsberg 34A, 45276 Essen, Germany.,Miquel Sans, Department of Digestive Diseases, Centro Médico Teknon, 12 Vilana, 08009 Barcelona, Spain.,Yehuda Chowers, Department of Gastroenterology, Rambam Health Care Campus Rappaport Faculty Of Medicine, 8 Ha'Aliya Street, PO Box 9602, 3109601 Haifa, Israel.,Gionata Fiorino, IRCCS Humanitas Research Hospital, Department of Gastroenterology, IBD Center, Via Manzoni, 56, 20089 Rozzano, Italy.,Pascal Juillerat, Department of Gastroenterology, University Clinic for Visceral Surgery and Medicine, University Hospital Bern Inselspital, Freiburgstrasse 10, 3010 Bern, Switzerland.,Gerassimos J. Mantzaris , Department of Gastroenterology, Evangelismos Hospital, 45-47 Ypsilandou Street, 10676 Athens, Greece.,Fernando Rizzello, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy.,Paolo Gionchetti, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy
| | - Alessandro Armuzzi
- Fernando Gomollón, Professor of Medicine, Hospital Clínico Universitario "Lozano Blesa", Universidad de Zaragoza, IIS Aragón, CIBEREHD, Zaragoza, Spain.,Axel Dignass, Department of Medicine I, Agaplesion Markus Hospital, Willhelm-Epstein-Straße 4, 60431 Frankfurt/Main, Germany.,Vito Annese, Department of Emergency, Division of Gastroenterology, University Hospital Careggi, Largo Giovanni Alessandro Brambilla, 3, 50134 Florence, Italy.,Herbert Tilg, Department of Internal Medicine I, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.,Gert Van Assche, Division of Gastroenterology and Hepatology, University Hospitals Leuven and University of Leuven, 49 Herestraat, 3000 Leuven, Belgium.,James O. Lindsay, Department of Gastroenterology, Barts Health NHS Trust, The Royal London Hospital, Whitechapel Road, London E1 1BB, UK.,Laurent Peyrin-Biroulet, Department of Gastroenterology and Inserm U954, Nancy University Hospital, Lorraine University, 54500 Vandoeuvre-Lès-Nancy, France.,Garret J. Cullen, Department of Gastroenterology, Centre for Colorectal Disease, St. Vincent's University Hospital, 4 Dublin, Ireland.,Marco Daperno, Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, 10128 Torino, Italy.,Torsten Kucharzik, Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Bögelstraße 1, 21339 Lüneburg, Germany.,Florian Rieder, Department of Pathobiology/NC22, Lerner Research Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA; Department of Gastroenterology, Hepatology and Nutrition/A3, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA.,Sven Almer, Department of Medicine, Solna, Karolinska Institute, and, IBD-unit, Center for Digestive Diseases, Karolinska University Hospital, 17176 Stockholm, Sweden.,Alessandro Armuzzi, Department of Internal Medicine, IBD Unit Complesso Integrato Columbus, Gemelli Hospital Catholic University Foundation, Via Giuseppe Moscati 31, 00168 Rome, Italy.,Marcus Harbord, Imperial College, London; and Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK.,Jost Langhorst, Department of Internal Medicine and Integrative Gastroenterology, University Duisburg-Essen, Kliniken Essen-Mitte, Am Deimelsberg 34A, 45276 Essen, Germany.,Miquel Sans, Department of Digestive Diseases, Centro Médico Teknon, 12 Vilana, 08009 Barcelona, Spain.,Yehuda Chowers, Department of Gastroenterology, Rambam Health Care Campus Rappaport Faculty Of Medicine, 8 Ha'Aliya Street, PO Box 9602, 3109601 Haifa, Israel.,Gionata Fiorino, IRCCS Humanitas Research Hospital, Department of Gastroenterology, IBD Center, Via Manzoni, 56, 20089 Rozzano, Italy.,Pascal Juillerat, Department of Gastroenterology, University Clinic for Visceral Surgery and Medicine, University Hospital Bern Inselspital, Freiburgstrasse 10, 3010 Bern, Switzerland.,Gerassimos J. Mantzaris , Department of Gastroenterology, Evangelismos Hospital, 45-47 Ypsilandou Street, 10676 Athens, Greece.,Fernando Rizzello, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy.,Paolo Gionchetti, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy
| | - Marcus Harbord
- Fernando Gomollón, Professor of Medicine, Hospital Clínico Universitario "Lozano Blesa", Universidad de Zaragoza, IIS Aragón, CIBEREHD, Zaragoza, Spain.,Axel Dignass, Department of Medicine I, Agaplesion Markus Hospital, Willhelm-Epstein-Straße 4, 60431 Frankfurt/Main, Germany.,Vito Annese, Department of Emergency, Division of Gastroenterology, University Hospital Careggi, Largo Giovanni Alessandro Brambilla, 3, 50134 Florence, Italy.,Herbert Tilg, Department of Internal Medicine I, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.,Gert Van Assche, Division of Gastroenterology and Hepatology, University Hospitals Leuven and University of Leuven, 49 Herestraat, 3000 Leuven, Belgium.,James O. Lindsay, Department of Gastroenterology, Barts Health NHS Trust, The Royal London Hospital, Whitechapel Road, London E1 1BB, UK.,Laurent Peyrin-Biroulet, Department of Gastroenterology and Inserm U954, Nancy University Hospital, Lorraine University, 54500 Vandoeuvre-Lès-Nancy, France.,Garret J. Cullen, Department of Gastroenterology, Centre for Colorectal Disease, St. Vincent's University Hospital, 4 Dublin, Ireland.,Marco Daperno, Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, 10128 Torino, Italy.,Torsten Kucharzik, Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Bögelstraße 1, 21339 Lüneburg, Germany.,Florian Rieder, Department of Pathobiology/NC22, Lerner Research Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA; Department of Gastroenterology, Hepatology and Nutrition/A3, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA.,Sven Almer, Department of Medicine, Solna, Karolinska Institute, and, IBD-unit, Center for Digestive Diseases, Karolinska University Hospital, 17176 Stockholm, Sweden.,Alessandro Armuzzi, Department of Internal Medicine, IBD Unit Complesso Integrato Columbus, Gemelli Hospital Catholic University Foundation, Via Giuseppe Moscati 31, 00168 Rome, Italy.,Marcus Harbord, Imperial College, London; and Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK.,Jost Langhorst, Department of Internal Medicine and Integrative Gastroenterology, University Duisburg-Essen, Kliniken Essen-Mitte, Am Deimelsberg 34A, 45276 Essen, Germany.,Miquel Sans, Department of Digestive Diseases, Centro Médico Teknon, 12 Vilana, 08009 Barcelona, Spain.,Yehuda Chowers, Department of Gastroenterology, Rambam Health Care Campus Rappaport Faculty Of Medicine, 8 Ha'Aliya Street, PO Box 9602, 3109601 Haifa, Israel.,Gionata Fiorino, IRCCS Humanitas Research Hospital, Department of Gastroenterology, IBD Center, Via Manzoni, 56, 20089 Rozzano, Italy.,Pascal Juillerat, Department of Gastroenterology, University Clinic for Visceral Surgery and Medicine, University Hospital Bern Inselspital, Freiburgstrasse 10, 3010 Bern, Switzerland.,Gerassimos J. Mantzaris , Department of Gastroenterology, Evangelismos Hospital, 45-47 Ypsilandou Street, 10676 Athens, Greece.,Fernando Rizzello, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy.,Paolo Gionchetti, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy
| | - Jost Langhorst
- Fernando Gomollón, Professor of Medicine, Hospital Clínico Universitario "Lozano Blesa", Universidad de Zaragoza, IIS Aragón, CIBEREHD, Zaragoza, Spain.,Axel Dignass, Department of Medicine I, Agaplesion Markus Hospital, Willhelm-Epstein-Straße 4, 60431 Frankfurt/Main, Germany.,Vito Annese, Department of Emergency, Division of Gastroenterology, University Hospital Careggi, Largo Giovanni Alessandro Brambilla, 3, 50134 Florence, Italy.,Herbert Tilg, Department of Internal Medicine I, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.,Gert Van Assche, Division of Gastroenterology and Hepatology, University Hospitals Leuven and University of Leuven, 49 Herestraat, 3000 Leuven, Belgium.,James O. Lindsay, Department of Gastroenterology, Barts Health NHS Trust, The Royal London Hospital, Whitechapel Road, London E1 1BB, UK.,Laurent Peyrin-Biroulet, Department of Gastroenterology and Inserm U954, Nancy University Hospital, Lorraine University, 54500 Vandoeuvre-Lès-Nancy, France.,Garret J. Cullen, Department of Gastroenterology, Centre for Colorectal Disease, St. Vincent's University Hospital, 4 Dublin, Ireland.,Marco Daperno, Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, 10128 Torino, Italy.,Torsten Kucharzik, Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Bögelstraße 1, 21339 Lüneburg, Germany.,Florian Rieder, Department of Pathobiology/NC22, Lerner Research Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA; Department of Gastroenterology, Hepatology and Nutrition/A3, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA.,Sven Almer, Department of Medicine, Solna, Karolinska Institute, and, IBD-unit, Center for Digestive Diseases, Karolinska University Hospital, 17176 Stockholm, Sweden.,Alessandro Armuzzi, Department of Internal Medicine, IBD Unit Complesso Integrato Columbus, Gemelli Hospital Catholic University Foundation, Via Giuseppe Moscati 31, 00168 Rome, Italy.,Marcus Harbord, Imperial College, London; and Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK.,Jost Langhorst, Department of Internal Medicine and Integrative Gastroenterology, University Duisburg-Essen, Kliniken Essen-Mitte, Am Deimelsberg 34A, 45276 Essen, Germany.,Miquel Sans, Department of Digestive Diseases, Centro Médico Teknon, 12 Vilana, 08009 Barcelona, Spain.,Yehuda Chowers, Department of Gastroenterology, Rambam Health Care Campus Rappaport Faculty Of Medicine, 8 Ha'Aliya Street, PO Box 9602, 3109601 Haifa, Israel.,Gionata Fiorino, IRCCS Humanitas Research Hospital, Department of Gastroenterology, IBD Center, Via Manzoni, 56, 20089 Rozzano, Italy.,Pascal Juillerat, Department of Gastroenterology, University Clinic for Visceral Surgery and Medicine, University Hospital Bern Inselspital, Freiburgstrasse 10, 3010 Bern, Switzerland.,Gerassimos J. Mantzaris , Department of Gastroenterology, Evangelismos Hospital, 45-47 Ypsilandou Street, 10676 Athens, Greece.,Fernando Rizzello, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy.,Paolo Gionchetti, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy
| | - Miquel Sans
- Fernando Gomollón, Professor of Medicine, Hospital Clínico Universitario "Lozano Blesa", Universidad de Zaragoza, IIS Aragón, CIBEREHD, Zaragoza, Spain.,Axel Dignass, Department of Medicine I, Agaplesion Markus Hospital, Willhelm-Epstein-Straße 4, 60431 Frankfurt/Main, Germany.,Vito Annese, Department of Emergency, Division of Gastroenterology, University Hospital Careggi, Largo Giovanni Alessandro Brambilla, 3, 50134 Florence, Italy.,Herbert Tilg, Department of Internal Medicine I, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.,Gert Van Assche, Division of Gastroenterology and Hepatology, University Hospitals Leuven and University of Leuven, 49 Herestraat, 3000 Leuven, Belgium.,James O. Lindsay, Department of Gastroenterology, Barts Health NHS Trust, The Royal London Hospital, Whitechapel Road, London E1 1BB, UK.,Laurent Peyrin-Biroulet, Department of Gastroenterology and Inserm U954, Nancy University Hospital, Lorraine University, 54500 Vandoeuvre-Lès-Nancy, France.,Garret J. Cullen, Department of Gastroenterology, Centre for Colorectal Disease, St. Vincent's University Hospital, 4 Dublin, Ireland.,Marco Daperno, Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, 10128 Torino, Italy.,Torsten Kucharzik, Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Bögelstraße 1, 21339 Lüneburg, Germany.,Florian Rieder, Department of Pathobiology/NC22, Lerner Research Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA; Department of Gastroenterology, Hepatology and Nutrition/A3, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA.,Sven Almer, Department of Medicine, Solna, Karolinska Institute, and, IBD-unit, Center for Digestive Diseases, Karolinska University Hospital, 17176 Stockholm, Sweden.,Alessandro Armuzzi, Department of Internal Medicine, IBD Unit Complesso Integrato Columbus, Gemelli Hospital Catholic University Foundation, Via Giuseppe Moscati 31, 00168 Rome, Italy.,Marcus Harbord, Imperial College, London; and Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK.,Jost Langhorst, Department of Internal Medicine and Integrative Gastroenterology, University Duisburg-Essen, Kliniken Essen-Mitte, Am Deimelsberg 34A, 45276 Essen, Germany.,Miquel Sans, Department of Digestive Diseases, Centro Médico Teknon, 12 Vilana, 08009 Barcelona, Spain.,Yehuda Chowers, Department of Gastroenterology, Rambam Health Care Campus Rappaport Faculty Of Medicine, 8 Ha'Aliya Street, PO Box 9602, 3109601 Haifa, Israel.,Gionata Fiorino, IRCCS Humanitas Research Hospital, Department of Gastroenterology, IBD Center, Via Manzoni, 56, 20089 Rozzano, Italy.,Pascal Juillerat, Department of Gastroenterology, University Clinic for Visceral Surgery and Medicine, University Hospital Bern Inselspital, Freiburgstrasse 10, 3010 Bern, Switzerland.,Gerassimos J. Mantzaris , Department of Gastroenterology, Evangelismos Hospital, 45-47 Ypsilandou Street, 10676 Athens, Greece.,Fernando Rizzello, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy.,Paolo Gionchetti, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy
| | - Yehuda Chowers
- Fernando Gomollón, Professor of Medicine, Hospital Clínico Universitario "Lozano Blesa", Universidad de Zaragoza, IIS Aragón, CIBEREHD, Zaragoza, Spain.,Axel Dignass, Department of Medicine I, Agaplesion Markus Hospital, Willhelm-Epstein-Straße 4, 60431 Frankfurt/Main, Germany.,Vito Annese, Department of Emergency, Division of Gastroenterology, University Hospital Careggi, Largo Giovanni Alessandro Brambilla, 3, 50134 Florence, Italy.,Herbert Tilg, Department of Internal Medicine I, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.,Gert Van Assche, Division of Gastroenterology and Hepatology, University Hospitals Leuven and University of Leuven, 49 Herestraat, 3000 Leuven, Belgium.,James O. Lindsay, Department of Gastroenterology, Barts Health NHS Trust, The Royal London Hospital, Whitechapel Road, London E1 1BB, UK.,Laurent Peyrin-Biroulet, Department of Gastroenterology and Inserm U954, Nancy University Hospital, Lorraine University, 54500 Vandoeuvre-Lès-Nancy, France.,Garret J. Cullen, Department of Gastroenterology, Centre for Colorectal Disease, St. Vincent's University Hospital, 4 Dublin, Ireland.,Marco Daperno, Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, 10128 Torino, Italy.,Torsten Kucharzik, Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Bögelstraße 1, 21339 Lüneburg, Germany.,Florian Rieder, Department of Pathobiology/NC22, Lerner Research Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA; Department of Gastroenterology, Hepatology and Nutrition/A3, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA.,Sven Almer, Department of Medicine, Solna, Karolinska Institute, and, IBD-unit, Center for Digestive Diseases, Karolinska University Hospital, 17176 Stockholm, Sweden.,Alessandro Armuzzi, Department of Internal Medicine, IBD Unit Complesso Integrato Columbus, Gemelli Hospital Catholic University Foundation, Via Giuseppe Moscati 31, 00168 Rome, Italy.,Marcus Harbord, Imperial College, London; and Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK.,Jost Langhorst, Department of Internal Medicine and Integrative Gastroenterology, University Duisburg-Essen, Kliniken Essen-Mitte, Am Deimelsberg 34A, 45276 Essen, Germany.,Miquel Sans, Department of Digestive Diseases, Centro Médico Teknon, 12 Vilana, 08009 Barcelona, Spain.,Yehuda Chowers, Department of Gastroenterology, Rambam Health Care Campus Rappaport Faculty Of Medicine, 8 Ha'Aliya Street, PO Box 9602, 3109601 Haifa, Israel.,Gionata Fiorino, IRCCS Humanitas Research Hospital, Department of Gastroenterology, IBD Center, Via Manzoni, 56, 20089 Rozzano, Italy.,Pascal Juillerat, Department of Gastroenterology, University Clinic for Visceral Surgery and Medicine, University Hospital Bern Inselspital, Freiburgstrasse 10, 3010 Bern, Switzerland.,Gerassimos J. Mantzaris , Department of Gastroenterology, Evangelismos Hospital, 45-47 Ypsilandou Street, 10676 Athens, Greece.,Fernando Rizzello, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy.,Paolo Gionchetti, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy
| | - Gionata Fiorino
- Fernando Gomollón, Professor of Medicine, Hospital Clínico Universitario "Lozano Blesa", Universidad de Zaragoza, IIS Aragón, CIBEREHD, Zaragoza, Spain.,Axel Dignass, Department of Medicine I, Agaplesion Markus Hospital, Willhelm-Epstein-Straße 4, 60431 Frankfurt/Main, Germany.,Vito Annese, Department of Emergency, Division of Gastroenterology, University Hospital Careggi, Largo Giovanni Alessandro Brambilla, 3, 50134 Florence, Italy.,Herbert Tilg, Department of Internal Medicine I, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.,Gert Van Assche, Division of Gastroenterology and Hepatology, University Hospitals Leuven and University of Leuven, 49 Herestraat, 3000 Leuven, Belgium.,James O. Lindsay, Department of Gastroenterology, Barts Health NHS Trust, The Royal London Hospital, Whitechapel Road, London E1 1BB, UK.,Laurent Peyrin-Biroulet, Department of Gastroenterology and Inserm U954, Nancy University Hospital, Lorraine University, 54500 Vandoeuvre-Lès-Nancy, France.,Garret J. Cullen, Department of Gastroenterology, Centre for Colorectal Disease, St. Vincent's University Hospital, 4 Dublin, Ireland.,Marco Daperno, Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, 10128 Torino, Italy.,Torsten Kucharzik, Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Bögelstraße 1, 21339 Lüneburg, Germany.,Florian Rieder, Department of Pathobiology/NC22, Lerner Research Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA; Department of Gastroenterology, Hepatology and Nutrition/A3, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA.,Sven Almer, Department of Medicine, Solna, Karolinska Institute, and, IBD-unit, Center for Digestive Diseases, Karolinska University Hospital, 17176 Stockholm, Sweden.,Alessandro Armuzzi, Department of Internal Medicine, IBD Unit Complesso Integrato Columbus, Gemelli Hospital Catholic University Foundation, Via Giuseppe Moscati 31, 00168 Rome, Italy.,Marcus Harbord, Imperial College, London; and Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK.,Jost Langhorst, Department of Internal Medicine and Integrative Gastroenterology, University Duisburg-Essen, Kliniken Essen-Mitte, Am Deimelsberg 34A, 45276 Essen, Germany.,Miquel Sans, Department of Digestive Diseases, Centro Médico Teknon, 12 Vilana, 08009 Barcelona, Spain.,Yehuda Chowers, Department of Gastroenterology, Rambam Health Care Campus Rappaport Faculty Of Medicine, 8 Ha'Aliya Street, PO Box 9602, 3109601 Haifa, Israel.,Gionata Fiorino, IRCCS Humanitas Research Hospital, Department of Gastroenterology, IBD Center, Via Manzoni, 56, 20089 Rozzano, Italy.,Pascal Juillerat, Department of Gastroenterology, University Clinic for Visceral Surgery and Medicine, University Hospital Bern Inselspital, Freiburgstrasse 10, 3010 Bern, Switzerland.,Gerassimos J. Mantzaris , Department of Gastroenterology, Evangelismos Hospital, 45-47 Ypsilandou Street, 10676 Athens, Greece.,Fernando Rizzello, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy.,Paolo Gionchetti, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy
| | - Pascal Juillerat
- Fernando Gomollón, Professor of Medicine, Hospital Clínico Universitario "Lozano Blesa", Universidad de Zaragoza, IIS Aragón, CIBEREHD, Zaragoza, Spain.,Axel Dignass, Department of Medicine I, Agaplesion Markus Hospital, Willhelm-Epstein-Straße 4, 60431 Frankfurt/Main, Germany.,Vito Annese, Department of Emergency, Division of Gastroenterology, University Hospital Careggi, Largo Giovanni Alessandro Brambilla, 3, 50134 Florence, Italy.,Herbert Tilg, Department of Internal Medicine I, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.,Gert Van Assche, Division of Gastroenterology and Hepatology, University Hospitals Leuven and University of Leuven, 49 Herestraat, 3000 Leuven, Belgium.,James O. Lindsay, Department of Gastroenterology, Barts Health NHS Trust, The Royal London Hospital, Whitechapel Road, London E1 1BB, UK.,Laurent Peyrin-Biroulet, Department of Gastroenterology and Inserm U954, Nancy University Hospital, Lorraine University, 54500 Vandoeuvre-Lès-Nancy, France.,Garret J. Cullen, Department of Gastroenterology, Centre for Colorectal Disease, St. Vincent's University Hospital, 4 Dublin, Ireland.,Marco Daperno, Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, 10128 Torino, Italy.,Torsten Kucharzik, Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Bögelstraße 1, 21339 Lüneburg, Germany.,Florian Rieder, Department of Pathobiology/NC22, Lerner Research Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA; Department of Gastroenterology, Hepatology and Nutrition/A3, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA.,Sven Almer, Department of Medicine, Solna, Karolinska Institute, and, IBD-unit, Center for Digestive Diseases, Karolinska University Hospital, 17176 Stockholm, Sweden.,Alessandro Armuzzi, Department of Internal Medicine, IBD Unit Complesso Integrato Columbus, Gemelli Hospital Catholic University Foundation, Via Giuseppe Moscati 31, 00168 Rome, Italy.,Marcus Harbord, Imperial College, London; and Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK.,Jost Langhorst, Department of Internal Medicine and Integrative Gastroenterology, University Duisburg-Essen, Kliniken Essen-Mitte, Am Deimelsberg 34A, 45276 Essen, Germany.,Miquel Sans, Department of Digestive Diseases, Centro Médico Teknon, 12 Vilana, 08009 Barcelona, Spain.,Yehuda Chowers, Department of Gastroenterology, Rambam Health Care Campus Rappaport Faculty Of Medicine, 8 Ha'Aliya Street, PO Box 9602, 3109601 Haifa, Israel.,Gionata Fiorino, IRCCS Humanitas Research Hospital, Department of Gastroenterology, IBD Center, Via Manzoni, 56, 20089 Rozzano, Italy.,Pascal Juillerat, Department of Gastroenterology, University Clinic for Visceral Surgery and Medicine, University Hospital Bern Inselspital, Freiburgstrasse 10, 3010 Bern, Switzerland.,Gerassimos J. Mantzaris , Department of Gastroenterology, Evangelismos Hospital, 45-47 Ypsilandou Street, 10676 Athens, Greece.,Fernando Rizzello, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy.,Paolo Gionchetti, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy
| | - Gerassimos J Mantzaris
- Fernando Gomollón, Professor of Medicine, Hospital Clínico Universitario "Lozano Blesa", Universidad de Zaragoza, IIS Aragón, CIBEREHD, Zaragoza, Spain.,Axel Dignass, Department of Medicine I, Agaplesion Markus Hospital, Willhelm-Epstein-Straße 4, 60431 Frankfurt/Main, Germany.,Vito Annese, Department of Emergency, Division of Gastroenterology, University Hospital Careggi, Largo Giovanni Alessandro Brambilla, 3, 50134 Florence, Italy.,Herbert Tilg, Department of Internal Medicine I, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.,Gert Van Assche, Division of Gastroenterology and Hepatology, University Hospitals Leuven and University of Leuven, 49 Herestraat, 3000 Leuven, Belgium.,James O. Lindsay, Department of Gastroenterology, Barts Health NHS Trust, The Royal London Hospital, Whitechapel Road, London E1 1BB, UK.,Laurent Peyrin-Biroulet, Department of Gastroenterology and Inserm U954, Nancy University Hospital, Lorraine University, 54500 Vandoeuvre-Lès-Nancy, France.,Garret J. Cullen, Department of Gastroenterology, Centre for Colorectal Disease, St. Vincent's University Hospital, 4 Dublin, Ireland.,Marco Daperno, Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, 10128 Torino, Italy.,Torsten Kucharzik, Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Bögelstraße 1, 21339 Lüneburg, Germany.,Florian Rieder, Department of Pathobiology/NC22, Lerner Research Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA; Department of Gastroenterology, Hepatology and Nutrition/A3, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA.,Sven Almer, Department of Medicine, Solna, Karolinska Institute, and, IBD-unit, Center for Digestive Diseases, Karolinska University Hospital, 17176 Stockholm, Sweden.,Alessandro Armuzzi, Department of Internal Medicine, IBD Unit Complesso Integrato Columbus, Gemelli Hospital Catholic University Foundation, Via Giuseppe Moscati 31, 00168 Rome, Italy.,Marcus Harbord, Imperial College, London; and Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK.,Jost Langhorst, Department of Internal Medicine and Integrative Gastroenterology, University Duisburg-Essen, Kliniken Essen-Mitte, Am Deimelsberg 34A, 45276 Essen, Germany.,Miquel Sans, Department of Digestive Diseases, Centro Médico Teknon, 12 Vilana, 08009 Barcelona, Spain.,Yehuda Chowers, Department of Gastroenterology, Rambam Health Care Campus Rappaport Faculty Of Medicine, 8 Ha'Aliya Street, PO Box 9602, 3109601 Haifa, Israel.,Gionata Fiorino, IRCCS Humanitas Research Hospital, Department of Gastroenterology, IBD Center, Via Manzoni, 56, 20089 Rozzano, Italy.,Pascal Juillerat, Department of Gastroenterology, University Clinic for Visceral Surgery and Medicine, University Hospital Bern Inselspital, Freiburgstrasse 10, 3010 Bern, Switzerland.,Gerassimos J. Mantzaris , Department of Gastroenterology, Evangelismos Hospital, 45-47 Ypsilandou Street, 10676 Athens, Greece.,Fernando Rizzello, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy.,Paolo Gionchetti, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy
| | - Fernando Rizzello
- Fernando Gomollón, Professor of Medicine, Hospital Clínico Universitario "Lozano Blesa", Universidad de Zaragoza, IIS Aragón, CIBEREHD, Zaragoza, Spain.,Axel Dignass, Department of Medicine I, Agaplesion Markus Hospital, Willhelm-Epstein-Straße 4, 60431 Frankfurt/Main, Germany.,Vito Annese, Department of Emergency, Division of Gastroenterology, University Hospital Careggi, Largo Giovanni Alessandro Brambilla, 3, 50134 Florence, Italy.,Herbert Tilg, Department of Internal Medicine I, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.,Gert Van Assche, Division of Gastroenterology and Hepatology, University Hospitals Leuven and University of Leuven, 49 Herestraat, 3000 Leuven, Belgium.,James O. Lindsay, Department of Gastroenterology, Barts Health NHS Trust, The Royal London Hospital, Whitechapel Road, London E1 1BB, UK.,Laurent Peyrin-Biroulet, Department of Gastroenterology and Inserm U954, Nancy University Hospital, Lorraine University, 54500 Vandoeuvre-Lès-Nancy, France.,Garret J. Cullen, Department of Gastroenterology, Centre for Colorectal Disease, St. Vincent's University Hospital, 4 Dublin, Ireland.,Marco Daperno, Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, 10128 Torino, Italy.,Torsten Kucharzik, Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Bögelstraße 1, 21339 Lüneburg, Germany.,Florian Rieder, Department of Pathobiology/NC22, Lerner Research Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA; Department of Gastroenterology, Hepatology and Nutrition/A3, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA.,Sven Almer, Department of Medicine, Solna, Karolinska Institute, and, IBD-unit, Center for Digestive Diseases, Karolinska University Hospital, 17176 Stockholm, Sweden.,Alessandro Armuzzi, Department of Internal Medicine, IBD Unit Complesso Integrato Columbus, Gemelli Hospital Catholic University Foundation, Via Giuseppe Moscati 31, 00168 Rome, Italy.,Marcus Harbord, Imperial College, London; and Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK.,Jost Langhorst, Department of Internal Medicine and Integrative Gastroenterology, University Duisburg-Essen, Kliniken Essen-Mitte, Am Deimelsberg 34A, 45276 Essen, Germany.,Miquel Sans, Department of Digestive Diseases, Centro Médico Teknon, 12 Vilana, 08009 Barcelona, Spain.,Yehuda Chowers, Department of Gastroenterology, Rambam Health Care Campus Rappaport Faculty Of Medicine, 8 Ha'Aliya Street, PO Box 9602, 3109601 Haifa, Israel.,Gionata Fiorino, IRCCS Humanitas Research Hospital, Department of Gastroenterology, IBD Center, Via Manzoni, 56, 20089 Rozzano, Italy.,Pascal Juillerat, Department of Gastroenterology, University Clinic for Visceral Surgery and Medicine, University Hospital Bern Inselspital, Freiburgstrasse 10, 3010 Bern, Switzerland.,Gerassimos J. Mantzaris , Department of Gastroenterology, Evangelismos Hospital, 45-47 Ypsilandou Street, 10676 Athens, Greece.,Fernando Rizzello, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy.,Paolo Gionchetti, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy
| | - Stephan Vavricka
- Fernando Gomollón, Professor of Medicine, Hospital Clínico Universitario "Lozano Blesa", Universidad de Zaragoza, IIS Aragón, CIBEREHD, Zaragoza, Spain.,Axel Dignass, Department of Medicine I, Agaplesion Markus Hospital, Willhelm-Epstein-Straße 4, 60431 Frankfurt/Main, Germany.,Vito Annese, Department of Emergency, Division of Gastroenterology, University Hospital Careggi, Largo Giovanni Alessandro Brambilla, 3, 50134 Florence, Italy.,Herbert Tilg, Department of Internal Medicine I, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.,Gert Van Assche, Division of Gastroenterology and Hepatology, University Hospitals Leuven and University of Leuven, 49 Herestraat, 3000 Leuven, Belgium.,James O. Lindsay, Department of Gastroenterology, Barts Health NHS Trust, The Royal London Hospital, Whitechapel Road, London E1 1BB, UK.,Laurent Peyrin-Biroulet, Department of Gastroenterology and Inserm U954, Nancy University Hospital, Lorraine University, 54500 Vandoeuvre-Lès-Nancy, France.,Garret J. Cullen, Department of Gastroenterology, Centre for Colorectal Disease, St. Vincent's University Hospital, 4 Dublin, Ireland.,Marco Daperno, Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, 10128 Torino, Italy.,Torsten Kucharzik, Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Bögelstraße 1, 21339 Lüneburg, Germany.,Florian Rieder, Department of Pathobiology/NC22, Lerner Research Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA; Department of Gastroenterology, Hepatology and Nutrition/A3, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA.,Sven Almer, Department of Medicine, Solna, Karolinska Institute, and, IBD-unit, Center for Digestive Diseases, Karolinska University Hospital, 17176 Stockholm, Sweden.,Alessandro Armuzzi, Department of Internal Medicine, IBD Unit Complesso Integrato Columbus, Gemelli Hospital Catholic University Foundation, Via Giuseppe Moscati 31, 00168 Rome, Italy.,Marcus Harbord, Imperial College, London; and Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK.,Jost Langhorst, Department of Internal Medicine and Integrative Gastroenterology, University Duisburg-Essen, Kliniken Essen-Mitte, Am Deimelsberg 34A, 45276 Essen, Germany.,Miquel Sans, Department of Digestive Diseases, Centro Médico Teknon, 12 Vilana, 08009 Barcelona, Spain.,Yehuda Chowers, Department of Gastroenterology, Rambam Health Care Campus Rappaport Faculty Of Medicine, 8 Ha'Aliya Street, PO Box 9602, 3109601 Haifa, Israel.,Gionata Fiorino, IRCCS Humanitas Research Hospital, Department of Gastroenterology, IBD Center, Via Manzoni, 56, 20089 Rozzano, Italy.,Pascal Juillerat, Department of Gastroenterology, University Clinic for Visceral Surgery and Medicine, University Hospital Bern Inselspital, Freiburgstrasse 10, 3010 Bern, Switzerland.,Gerassimos J. Mantzaris , Department of Gastroenterology, Evangelismos Hospital, 45-47 Ypsilandou Street, 10676 Athens, Greece.,Fernando Rizzello, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy.,Paolo Gionchetti, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy
| | - Paolo Gionchetti
- Fernando Gomollón, Professor of Medicine, Hospital Clínico Universitario "Lozano Blesa", Universidad de Zaragoza, IIS Aragón, CIBEREHD, Zaragoza, Spain.,Axel Dignass, Department of Medicine I, Agaplesion Markus Hospital, Willhelm-Epstein-Straße 4, 60431 Frankfurt/Main, Germany.,Vito Annese, Department of Emergency, Division of Gastroenterology, University Hospital Careggi, Largo Giovanni Alessandro Brambilla, 3, 50134 Florence, Italy.,Herbert Tilg, Department of Internal Medicine I, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.,Gert Van Assche, Division of Gastroenterology and Hepatology, University Hospitals Leuven and University of Leuven, 49 Herestraat, 3000 Leuven, Belgium.,James O. Lindsay, Department of Gastroenterology, Barts Health NHS Trust, The Royal London Hospital, Whitechapel Road, London E1 1BB, UK.,Laurent Peyrin-Biroulet, Department of Gastroenterology and Inserm U954, Nancy University Hospital, Lorraine University, 54500 Vandoeuvre-Lès-Nancy, France.,Garret J. Cullen, Department of Gastroenterology, Centre for Colorectal Disease, St. Vincent's University Hospital, 4 Dublin, Ireland.,Marco Daperno, Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, 10128 Torino, Italy.,Torsten Kucharzik, Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Bögelstraße 1, 21339 Lüneburg, Germany.,Florian Rieder, Department of Pathobiology/NC22, Lerner Research Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA; Department of Gastroenterology, Hepatology and Nutrition/A3, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, 44195 Cleveland, OH, USA.,Sven Almer, Department of Medicine, Solna, Karolinska Institute, and, IBD-unit, Center for Digestive Diseases, Karolinska University Hospital, 17176 Stockholm, Sweden.,Alessandro Armuzzi, Department of Internal Medicine, IBD Unit Complesso Integrato Columbus, Gemelli Hospital Catholic University Foundation, Via Giuseppe Moscati 31, 00168 Rome, Italy.,Marcus Harbord, Imperial College, London; and Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK.,Jost Langhorst, Department of Internal Medicine and Integrative Gastroenterology, University Duisburg-Essen, Kliniken Essen-Mitte, Am Deimelsberg 34A, 45276 Essen, Germany.,Miquel Sans, Department of Digestive Diseases, Centro Médico Teknon, 12 Vilana, 08009 Barcelona, Spain.,Yehuda Chowers, Department of Gastroenterology, Rambam Health Care Campus Rappaport Faculty Of Medicine, 8 Ha'Aliya Street, PO Box 9602, 3109601 Haifa, Israel.,Gionata Fiorino, IRCCS Humanitas Research Hospital, Department of Gastroenterology, IBD Center, Via Manzoni, 56, 20089 Rozzano, Italy.,Pascal Juillerat, Department of Gastroenterology, University Clinic for Visceral Surgery and Medicine, University Hospital Bern Inselspital, Freiburgstrasse 10, 3010 Bern, Switzerland.,Gerassimos J. Mantzaris , Department of Gastroenterology, Evangelismos Hospital, 45-47 Ypsilandou Street, 10676 Athens, Greece.,Fernando Rizzello, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy.,Paolo Gionchetti, IBD Unit, DIMEC, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy
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Ungar B, Kopylov U, Engel T, Yavzori M, Fudim E, Picard O, Lang A, Williet N, Paul S, Chowers Y, Bar-Gil Shitrit A, Eliakim R, Ben-Horin S, Roblin X. Addition of an immunomodulator can reverse antibody formation and loss of response in patients treated with adalimumab. Aliment Pharmacol Ther 2017. [PMID: 27862102 DOI: 10.1111/apt.13862s] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Anti-adalimumab antibodies (AAA) are associated with loss of clinical response (LOR). Addition of an immunomodulator has been shown to reverse immunogenicity and regain response with infliximab monotherapy. Similar data on adalimumab are lacking. AIM To study the impact of immunomodulator addition on the emergence of AAA and LOR among adalimumab therapy patients. METHODS The databases of three tertiary medical centres were reviewed to identify patients who developed AAA during adalimumab monotherapy with resultant LOR, and received an immunomodulator as a salvage combination therapy. All sera were prospectively analysed using previously described ELISA assays. Clinical response was determined using appropriate clinical scores. Elimination of AAA, designated as 'sero-reversal', elevation of drug levels and regained clinical response were the sought outcomes. RESULTS Twenty-three patients (21 Crohn's disease, and 2 ulcerative colitis) developed AAA with subsequent LOR and were thereafter prescribed an immunomodulator as salvage therapy (thiopurine n = 14, methotrexate n = 9). Eleven patients (48%) underwent sero-reversal with gradual elimination of AAA, increase in drug trough levels and restoration of clinical response (median time to sero-reversal 5 months). In 12 patients (52%), immunogenicity and loss of response could not be reversed. There was no difference between responders and nonresponders in the type of immunomodulators used or baseline clinical characteristics. CONCLUSIONS In almost half of inflammatory bowel disease patients developing anti-adalimumab antibodies and loss of response, established immunogenicity of adalimumab can be gradually reversed by the addition of immunomodulator therapy with restoration of a clinico-biological response. However, these observations need to be confirmed with larger studies.
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Affiliation(s)
- B Ungar
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - U Kopylov
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - T Engel
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - M Yavzori
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - E Fudim
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - O Picard
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - A Lang
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - N Williet
- Service de Gastrologie-Entérologie-Hépatologie, CHU de Saint-Etienne, Saint-Etienne, France
| | - S Paul
- Service de Gastrologie-Entérologie-Hépatologie, CHU de Saint-Etienne, Saint-Etienne, France
| | - Y Chowers
- Rambam Health Care Campus, Bruce & Ruth Rappaport School of Medicine, Technion Institute of Technology, Haifa, Israel
| | - A Bar-Gil Shitrit
- Digestive Diseases Institute, Shaare Zedek Medical Center, Jerusalem, Israel
| | - R Eliakim
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - S Ben-Horin
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - X Roblin
- Service de Gastrologie-Entérologie-Hépatologie, CHU de Saint-Etienne, Saint-Etienne, France
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Ungar B, Kopylov U, Engel T, Yavzori M, Fudim E, Picard O, Lang A, Williet N, Paul S, Chowers Y, Bar-Gil Shitrit A, Eliakim R, Ben-Horin S, Roblin X. Addition of an immunomodulator can reverse antibody formation and loss of response in patients treated with adalimumab. Aliment Pharmacol Ther 2017; 45:276-282. [PMID: 27862102 DOI: 10.1111/apt.13862] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [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: 08/20/2016] [Revised: 09/15/2016] [Accepted: 10/24/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anti-adalimumab antibodies (AAA) are associated with loss of clinical response (LOR). Addition of an immunomodulator has been shown to reverse immunogenicity and regain response with infliximab monotherapy. Similar data on adalimumab are lacking. AIM To study the impact of immunomodulator addition on the emergence of AAA and LOR among adalimumab therapy patients. METHODS The databases of three tertiary medical centres were reviewed to identify patients who developed AAA during adalimumab monotherapy with resultant LOR, and received an immunomodulator as a salvage combination therapy. All sera were prospectively analysed using previously described ELISA assays. Clinical response was determined using appropriate clinical scores. Elimination of AAA, designated as 'sero-reversal', elevation of drug levels and regained clinical response were the sought outcomes. RESULTS Twenty-three patients (21 Crohn's disease, and 2 ulcerative colitis) developed AAA with subsequent LOR and were thereafter prescribed an immunomodulator as salvage therapy (thiopurine n = 14, methotrexate n = 9). Eleven patients (48%) underwent sero-reversal with gradual elimination of AAA, increase in drug trough levels and restoration of clinical response (median time to sero-reversal 5 months). In 12 patients (52%), immunogenicity and loss of response could not be reversed. There was no difference between responders and nonresponders in the type of immunomodulators used or baseline clinical characteristics. CONCLUSIONS In almost half of inflammatory bowel disease patients developing anti-adalimumab antibodies and loss of response, established immunogenicity of adalimumab can be gradually reversed by the addition of immunomodulator therapy with restoration of a clinico-biological response. However, these observations need to be confirmed with larger studies.
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Affiliation(s)
- B Ungar
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - U Kopylov
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - T Engel
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - M Yavzori
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - E Fudim
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - O Picard
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - A Lang
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - N Williet
- Service de Gastrologie-Entérologie-Hépatologie, CHU de Saint-Etienne, Saint-Etienne, France
| | - S Paul
- Service de Gastrologie-Entérologie-Hépatologie, CHU de Saint-Etienne, Saint-Etienne, France
| | - Y Chowers
- Rambam Health Care Campus, Bruce & Ruth Rappaport School of Medicine, Technion Institute of Technology, Haifa, Israel
| | - A Bar-Gil Shitrit
- Digestive Diseases Institute, Shaare Zedek Medical Center, Jerusalem, Israel
| | - R Eliakim
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - S Ben-Horin
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - X Roblin
- Service de Gastrologie-Entérologie-Hépatologie, CHU de Saint-Etienne, Saint-Etienne, France
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46
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Afonso J, Lopes S, Gonçalves R, Caldeira P, Lago P, Tavares de Sousa H, Ramos J, Gonçalves AR, Ministro P, Rosa I, Vieira AI, Coelho R, Tavares P, Soares J, Sousa AL, Carvalho D, Sousa P, da Silva JP, Meira T, Silva Ferreira F, Dias CC, Chowers Y, Ben-Horin S, Magro F. Detection of anti-infliximab antibodies is impacted by antibody titer, infliximab level and IgG4 antibodies: a systematic comparison of three different assays. Therap Adv Gastroenterol 2016; 9:781-794. [PMID: 27803733 PMCID: PMC5076767 DOI: 10.1177/1756283x16658223] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [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] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND There is scant information on the accuracy of different assays used to measure anti-infliximab antibodies (ADAs), especially in the presence of detectable infliximab (IFX). We thus aimed to evaluate and compare three different assays for the detection of IFX and ADAs and to clarify the impact of the presence of circulating IFX on the accuracy of the ADA assays. METHODS Blood samples from 79 ulcerative colitis (UC) patients treated with infliximab were assessed for IFX levels and ADAs using three different assays: an in-house assay and two commercial kits, Immundiagnostik and Theradiag. Sera samples with ADAs and undetectable levels of IFX were spiked with exogenous IFX and analyzed for ADAs. RESULTS The three assays showed 81-96% agreement for the measured IFX level. However, the in-house assay and Immundiagnostik assays detected ADAs in 34 out of 79 samples, whereas Theradiag only detected ADAs in 24 samples. Samples negative for ADAs with Theradiag, but ADA-positive in both the in-house and Immundiagnostik assays, were positive for IFX or IgG4 ADAs. In spiking experiments, a low concentration of exogenous IFX (5 µg/ml) hampered ADA detection with Theradiag in sera samples with ADA levels of between 3 and 10 µg/ml. In the Immundiagnostik assay detection interference was only observed at concentrations of exogenous IFX higher than 30 µg/ml. However, in samples with high levels of ADAs (>25 µg/ml) interference was only observed at IFX concentrations higher than 100 µg/ml in all three assays. Binary (IFX/ADA) stratification of the results showed that IFX+/ADA- and IFX-/ADAs+ were less influenced by the assay results than the double-positive (IFX+/ADAs+) and double-negative (IFX-/ADAs-) combination. CONCLUSIONS All three methodologies are equally suitable for measuring IFX levels. However, erroneous therapeutic decisions may occur when patients show double-negative (IFX-/ADAs-) or double-positive (IFX+/ADAs+) status, since agreement between assays is significantly lower in these circumstances.
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Affiliation(s)
- Joana Afonso
- Department of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal MedInUP, Centre for Drug Discovery and Innovative Medicines, University of Porto, 4200 Porto, Portugal
| | - Susana Lopes
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
| | | | - Paulo Caldeira
- Gastroenterology Department, Centro Hospitalar do Algarve, Faro, Portugal
| | - Paula Lago
- Gastroenterology Department, Centro Hospitalar do Porto, Porto, Portugal
| | - Helena Tavares de Sousa
- Gastroenterology Department, Centro Hospitalar do Algarve, Portimão, Portugal Departament of Medicine e Medical Biosciences, University of Algarve, Faro, Portugal
| | - Jaime Ramos
- Gastroenterology Department, Centro Hospitalar de Lisboa, Lisboa, Portugal
| | - Ana Rita Gonçalves
- Gastroenterology Department, Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Paula Ministro
- Gastroenterology Department, Hospital de S. Teotónio, Viseu, Portugal
| | - Isadora Rosa
- Gastroenterology Department, Instituto Português de Oncologia de Lisboa, Lisboa, Portugal
| | - Ana Isabel Vieira
- Gastroenterology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Rosa Coelho
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
| | - Patrícia Tavares
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
| | - João Soares
- Gastroenterology Department, Hospital de Braga, Braga, Portugal
| | - Ana Lúcia Sousa
- Gastroenterology Department, Centro Hospitalar do Algarve, Faro, Portugal
| | - Diana Carvalho
- Gastroenterology Department, Centro Hospitalar de Lisboa, Lisboa, Portugal
| | - Paula Sousa
- Gastroenterology Department, Hospital de S. Teotónio, Viseu, Portugal
| | - João Pereira da Silva
- Gastroenterology Department, Instituto Português de Oncologia de Lisboa, Lisboa, Portugal
| | - Tânia Meira
- Gastroenterology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Filipa Silva Ferreira
- Department of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal MedInUP, Centre for Drug Discovery and Innovative Medicines, University of Porto, 4200 Porto, Portugal
| | - Cláudia Camila Dias
- Department of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Yehuda Chowers
- Gastroenterology Department, Rambam Health Care Campus and Bruce Rappaport School of Medicine, Technion Israel Institute of Technology, Israel
| | - Shomron Ben-Horin
- IBD Service, Department of Gastroenterology, Sheba Medical Center and Sackler School of Medicine, Tel-Aviv University, Israel
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Klein A, Mazor Y, Karban A, Ben-Itzhak O, Chowers Y, Sabo E. Early histological findings may predict the clinical phenotype in Crohn's colitis. United European Gastroenterol J 2016; 5:694-701. [PMID: 28815033 DOI: 10.1177/2050640616676435] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 10/03/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND AIMS Predicting the clinical course of Crohn's disease (CD) is relevant for treatment selection. Currently, such diagnostic tools are lacking. In a previous pilot study, morphometric tissue image analysis showed promise in predicting the clinical phenotype and need for surgery. In this study, we aimed to validate our previous results on a larger cohort. METHODS Colonic biopsies from CD patients with colonic or ileocolonic disease and at least five years of post-biopsy clinical follow-up were analyzed. The results were used to predict post-biopsy clinical phenotypes and outcomes. Data analysis was performed using multivariate regression models, discriminant score (DS) computations and Neural Network (NNET). RESULTS Multivariate analysis of morphometric variables differentiated between B1 and B2 phenotypes (sensitivity 81%, specificity 74%, accuracy on cross-validation 75%; area under the curve (AUC) of 0.74 (CI 0.6-0.84; NNET model sensitivity 87%, specificity 67% on the testing population)). Differentiation between B1 and B3 phenotypes was also possible (sensitivity 69%, specificity 76%, accuracy 70.5% on cross-validation; AUC 0.78 (CI 0.68-0.89); NNET model sensitivity 78%, specificity 77% on the testing population)). Differentiating between B2 and B3 phenotypes was not possible using morphometric variables. Multivariate analysis predicted surgery (sensitivity 67%, specificity 72.5%, accuracy 69%; AUC 0.72 (CI 0.61-0.82); NNET model sensitivity 80%, specificity 91% on the testing population)). CONCLUSIONS This study validates previous results and suggests that morphometric image analysis of early biopsies from Crohn's colitis patients may contribute to the prediction of future outcomes such as clinical phenotype and surgery. Prospective validation on larger cohorts is still needed.
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Affiliation(s)
- Amir Klein
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Yoav Mazor
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Amir Karban
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Ofer Ben-Itzhak
- Department of Pathology, Rambam Health Care Campus, Haifa, Israel
| | - Yehuda Chowers
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Edmond Sabo
- Department of Pathology, Rambam Health Care Campus, Haifa, Israel
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48
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Waterman M, Kurnik D, Chowers Y. Is Super-Selective Superior? J Crohns Colitis 2016; 10:1129-31. [PMID: 27402914 DOI: 10.1093/ecco-jcc/jjw128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 06/23/2016] [Indexed: 02/08/2023]
Affiliation(s)
- Matti Waterman
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel B. Rappaport Faculty of Medicine, The Technion - Israel Institute of Technology, Haifa, Israel
| | - Daniel Kurnik
- B. Rappaport Faculty of Medicine, The Technion - Israel Institute of Technology, Haifa, Israel Section of Clinical Pharmacology and Toxicology, Rambam Health Care Campus, Haifa, Israel
| | - Yehuda Chowers
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel B. Rappaport Faculty of Medicine, The Technion - Israel Institute of Technology, Haifa, Israel
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49
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O'Byrne S, Kaser A, Parik A, Chowers Y. Discovery of Biomarkers of Response in Early Drug Development. J Crohns Colitis 2016; 10 Suppl 2:S560-6. [PMID: 27302971 DOI: 10.1093/ecco-jcc/jjw115] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 01/22/2016] [Accepted: 05/16/2016] [Indexed: 02/08/2023]
Abstract
Ulcerative colitis and Crohn's disease have traditionally been managed by incrementally stepping up within a hierarchy of therapeutic classes consequent to failing a given therapeutic─necessitated by the notion that any type of therapeutic will only induce clinical response and remission in a fraction of, but not all, patients. Hence, the selection of therapies approximates stage of disease rather than patient-specific characteristics that would allow selection of a specific mechanism of action for therapeutic intervention. Development of prognostic biomarkers [to identify patients with more aggressive disease and a worse prognosis], as well as predictive biomarkers [to predict response or non-response to a particular therapy], has been identified as a key requirement for attainment of better overall response rates or to improve the response of the most severely ill patient subgroup. Since the state of biomarker development is early and the process in inflammatory bowel disease appears more complex than in other therapeutic areas such as oncology, profiling of potential biomarkers across broad populations of undifferentiated patients will be important in refining current hypotheses and progressing their study and validation.
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Affiliation(s)
| | - Arthur Kaser
- Division of Gastroenterology and Hepatology, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Asit Parik
- Takeda Pharmaceuticals International, Cambridge, MA, USA
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50
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Kopylov U, Klang E, Yablecovitch D, Lahat A, Avidan B, Neuman S, Levhar N, Greener T, Rozendorn N, Beytelman A, Yanai H, Dotan I, Chowers Y, Weiss B, Ben-Horin S, Amitai MM, Eliakim R. Magnetic resonance enterography versus capsule endoscopy activity indices for quantification of small bowel inflammation in Crohn's disease. Therap Adv Gastroenterol 2016; 9:655-63. [PMID: 27582877 PMCID: PMC4984327 DOI: 10.1177/1756283x16649143] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [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] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Video capsule endoscopy (VCE) and magnetic resonance enterography (MRE) are the prime modalities for the evaluation of small bowel (SB) Crohn's disease (CD). Mucosal inflammation on VCE is quantified using the Lewis score (LS). Diffusion-weighted (DW) magnetic resonance imaging (MRI) allows for accurate assessment of SB inflammation without administration of intravenous contrast material. The Magnetic Resonance Index of Activity (MaRiA) and the Clermont index are quantitative activity indices validated for contrast-enhanced MRE and DW-MRE, respectively. The aim of this study was to compare the quantification of distal SB inflammation by VCE and MR-related activity indices. METHODS Patients with known quiescent SB CD were prospectively recruited and underwent MRE and VCE. LS, MaRIA and Clermont scores were calculated for the distal SB. RESULTS Both MRI-based indices significantly correlated with the LS and the Clermont index (r = 0.50, p = 0.001 and r = 0.53, p = 0.001, respectively). Both MaRIA and Clermont scores were significantly lower in patients with mucosal healing (LS < 135). The area under the curve (AUC) with both MR scores was moderate for prediction of any mucosal inflammation (LS ⩾ 135) and excellent for prediction of moderate-to-severe inflammation (LS ⩾ 790) (0.71 and 0.74 versus 0.93 and 0.91 for MaRIA and Clermont score, respectively). CONCLUSIONS Modest correlation between VCE- and MRE-based quantitative indices of inflammation in patients with quiescent SB CD was observed. Between-modality correlation was higher in patients with endoscopically severe disease. DW-MRE gauged by Clermont score was at least as accurate as contrast-enhanced MRE for quantification of SB inflammation.
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Affiliation(s)
| | - Eyal Klang
- Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, Israel,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Doron Yablecovitch
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Israel,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Adi Lahat
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Israel,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Benjamin Avidan
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Israel,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Sandra Neuman
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Israel,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Nina Levhar
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Israel,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Tomer Greener
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Israel,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Noa Rozendorn
- Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, Israel,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Arkadi Beytelman
- Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, Israel,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Henit Yanai
- IBD Center, Department of Gastroenterology and Liver Diseases, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Iris Dotan
- IBD Center, Department of Gastroenterology and Liver Diseases, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Yehuda Chowers
- Rambam Health Care Campus, Haifa, Israel,Bruce Rappaport School of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Batya Weiss
- Edmond and Lily Safra Children’s Hospital, Tel Hashomer, Israel,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Shomron Ben-Horin
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Israel,Sackler Faculty of Medicine, Tel Aviv University, Israel
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