1
|
Vieujean S, Lindsay JO, D'Amico F, Ahuja V, Silverberg MS, Sood A, Yamamoto-Furusho JK, Nagahori M, Watanabe M, Koutroubakis IE, Foteinogiannopoulou K, Avni Biron I, Walsh A, Outtier A, Nordestgaard RLM, Abreu MT, Dubinsky M, Siegel C, Louis E, Dotan I, Reinisch W, Danese S, Rubin DT, Peyrin-Biroulet L. Analysis of Clinical Trial Screen Failures in Inflammatory Bowel Diseases [IBD]: Real World Results from the International Organization for the study of IBD. J Crohns Colitis 2024; 18:548-559. [PMID: 37864829 DOI: 10.1093/ecco-jcc/jjad180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Indexed: 10/23/2023]
Abstract
BACKGROUND Recruitment for randomized controlled trials [RCTs] in inflammatory bowel diseases [IBD] has substantially dropped over time. This study aimed to assess reasons why IBD patients are not included in sponsored multicentre phase IIb-III RCTs. METHODS All IOIBD members [n = 58] were invited to participate. We divided barriers to participation as follows: [1] reasons patients with active IBD were not deemed appropriate for an RCT; [2] reasons qualified patients did not wish to participate; and [3] reasons for screen failure [SF] in patients agreeing to participate. We assess these in a 4-week prospective study including, consecutively, all patients with symptomatic disease for whom a treatment change was required. In addition, we performed a 6-month retrospective study to further evaluate reasons for SF. RESULTS A total of 106 patients (60 male [56.6%], 63 Crohn's disease [CD] [59.4%]), from ten centres across the world, were included in the prospective study. An RCT has not been proposed to 65 of them [mainly due to eligibility criteria]. Of the 41 patients to whom an RCT was offered, eight refused [mainly due to reluctance to receive placebo] and 28 agreed to participate. Among these 28 patients, five failed their screening and 23 were finally included in an RCT. A total of 107 patients (61 male [57%], 67 CD [62.6%]), from 13 centres worldwide, were included in our retrospective study of SFs. The main reason was insufficient disease activity. CONCLUSION This first multicentre study analysing reasons for non-enrolment in IBD RCTs shows that we lose patients at each step. Eligibility criteria, the risk of placebo assignment, and insufficient disease activity were part of the main barriers.
Collapse
Affiliation(s)
- Sophie Vieujean
- Hepato-Gastroenterology and Digestive Oncology, University Hospital CHU of Liège, Liège, Belgium
| | - James O Lindsay
- Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK; Department of Gastroenterology, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Ferdinando D'Amico
- Department of Gastroenterology and Endoscopy, IRCCS San Raffaele Hospital and Vita-Salute San Raffaele University, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Vineet Ahuja
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Ajit Sood
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiāna, Punjab, India
| | - Jesus K Yamamoto-Furusho
- Inflammatory Bowel Disease Clinic, Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpa, Mexico
| | - Masakazu Nagahori
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Mamoru Watanabe
- Advanced Research Institute, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ioannis E Koutroubakis
- Department of Gastroenterology, University Hospital of Heraklion, Heraklion, Crete, Greece
| | | | - Irit Avni Biron
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alissa Walsh
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | - An Outtier
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | | | - Maria T Abreu
- Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Marla Dubinsky
- Division of Pediatric Gastroenterology and Nutrition, Icahn School of Medicine, Mount Sinai, New York, NY, USA
| | - Corey Siegel
- Inflammatory Bowel Disease Center, Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Edouard Louis
- Hepato-Gastroenterology and Digestive Oncology, University Hospital CHU of Liège, Liège, Belgium
| | - Iris Dotan
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Walter Reinisch
- Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Silvio Danese
- Department of Gastroenterology and Endoscopy, IRCCS San Raffaele Hospital and Vita-Salute San Raffaele University, Milan, Italy
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology, Nancy University Hospital, F-54500 Vandœuvre-lès-Nancy, France
- INSERM, NGERE, University of Lorraine, F-54000 Nancy, France
- INFINY Institute, Nancy University Hospital, F-54500 Vandœuvre-lès-Nancy, France
- FHU-CURE, Nancy University Hospital, F-54500 Vandœuvre-lès-Nancy, France
- Groupe Hospitalier privé Ambroise Paré - Hartmann, Paris IBD center, 92200 Neuilly sur Seine, France
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
| |
Collapse
|
2
|
Outtier A, Gijbels L, Noman M, Verstockt B, Sabino J, Vermeire S, Ferrante M. Screening Failure in a Large Clinical Trial Centre for Inflammatory Bowel Diseases: Rates, Causes, and Outcomes. Inflamm Bowel Dis 2023; 29:1440-1445. [PMID: 36350998 DOI: 10.1093/ibd/izac227] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Patients with inflammatory bowel diseases (IBD) sometimes require investigational medicinal therapy in a clinical trial. Before enrollment, patients must meet strict eligibility criteria, hampering recruitment rates. We investigated the rates, causes, and outcomes of screening failure (SF) in a tertiary IBD center. METHODS We reviewed all IBD patients screened for sponsored multicenter phase 1-3 induction studies with available global SF rates between January 2008 and March 2021. We compared our SF rates with the global SF rates. Causes of SF were categorized into disease activity, hematology, chemistry, microbiology, protocol violation, and withdrawal of consent. Patient outcomes were categorized into rescreening for the same trial, screening for another trial, (re)introduction of commercially available therapy, surgery, or watchful waiting. RESULTS During the study period, 642 local screenings were performed as part of 53 studies. We identified an overall SF rate of 17.1%, compared with 39.2% in the global study population (P < .00001). Causes of SF at our center included ineligible disease activity (36.4%), microbiology (25.5%), protocol violation (16.4%), withdrawal of consent (9.1%), chemistry (6.4%) and hematology (6.4%). Thirty SFs could have been avoided by prescreening that was more thorough. After SF, 34 patients were rescreened for the same trial, 17 screened for another trial, 38 initiated approved therapy, 9 were referred for surgery, and 12 did not receive further therapy. CONCLUSIONS A significant proportion of IBD patients consenting to clinical trials fail their screening. Main causes of SF are ineligible disease activity and abnormal finding on microbiology. Approximately one-fourth of SFs could have been avoided by prescreening that was more thorough.
Collapse
Affiliation(s)
- An Outtier
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
- Translational Research in Gastrointestinal Disorders, Department of Chronic Disease, and Metabolism, KU Leuven, Leuven, Belgium
| | - Liese Gijbels
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Maja Noman
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
- Translational Research in Gastrointestinal Disorders, Department of Chronic Disease, and Metabolism, KU Leuven, Leuven, Belgium
| | - João Sabino
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
- Translational Research in Gastrointestinal Disorders, Department of Chronic Disease, and Metabolism, KU Leuven, Leuven, Belgium
| | - Séverine Vermeire
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
- Translational Research in Gastrointestinal Disorders, Department of Chronic Disease, and Metabolism, KU Leuven, Leuven, Belgium
| | - Marc Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
- Translational Research in Gastrointestinal Disorders, Department of Chronic Disease, and Metabolism, KU Leuven, Leuven, Belgium
| |
Collapse
|
3
|
De Sutter E, Verreydt S, Yskout K, Geerts D, Borry P, Outtier A, Ferrante M, Vandermeulen C, Vanmechelen N, Van der Schueren B, Huys I. Using provocative design to foster electronic informed consent innovation. BMC Med Inform Decis Mak 2022; 22:296. [PMCID: PMC9669523 DOI: 10.1186/s12911-022-02039-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 11/03/2022] [Indexed: 11/18/2022] Open
Abstract
Background The development of technological applications in clinical research, such as electronic informed consent (eIC), is on the rise. The involvement of end users throughout the design process of eIC is of utmost importance to improve the current informed consent process. Methods Using a provocative design, we conducted interviews with 30 clinical research participants. Provotypes were used as a starting base to discuss various aspects relevant to eIC. By providing a medium to encourage divergent thinking, participants’ views and concerns were solicited. Thematic analysis was undertaken using NVivo. Results The majority of participants placed trust in the principal investigator or the hospital to perform the role of eIC hosting party. Differing opinions were reported on the amount of information required related to stakeholders’ access to an eIC system, and thus, to participants’ personal data, to enable trust in an eIC system. Nevertheless, this study indicates a general willingness of participants to share personal data with physicians and pharmaceutical companies on an international level, and to receive requests for new research studies via an eIC system. Participants suggested to tailor an eIC system based upon their preferences, for example, regarding whom they want to share their personal data with. Moreover, they expressed a desire to choose how they can contact the research team, and to indicate which study-related information they would like to receive electronically. In addition, positive opinions were voiced on the integration of a test to assess participants’ understanding before providing their eIC. Conclusions Following a research through design approach, insights have been generated which inform the design of eIC. Provotypes were designed to help participants think beyond what is familiar to them. Study findings revealed that not all situations were perceived as provocative, because of participants’ motivation to advance scientific research and the trust they place in the research team. Nevertheless, the use of provocative design resulted in additional insights, generated by clinical research participants, which could be considered in the further design of eIC. Supplementary Information The online version contains supplementary material available at 10.1186/s12911-022-02039-6.
Collapse
Affiliation(s)
- Evelien De Sutter
- grid.5596.f0000 0001 0668 7884Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Stef Verreydt
- grid.5596.f0000 0001 0668 7884Distributed and Secure Software (DistriNet), Department of Computer Science, KU Leuven, Leuven, Belgium
| | - Koen Yskout
- grid.5596.f0000 0001 0668 7884Distributed and Secure Software (DistriNet), Department of Computer Science, KU Leuven, Leuven, Belgium
| | - David Geerts
- grid.5596.f0000 0001 0668 7884KU Leuven Digital Society Institute, KU Leuven, Leuven, Belgium
| | - Pascal Borry
- grid.5596.f0000 0001 0668 7884Centre for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - An Outtier
- grid.5596.f0000 0001 0668 7884Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Marc Ferrante
- grid.5596.f0000 0001 0668 7884Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Corinne Vandermeulen
- grid.5596.f0000 0001 0668 7884Leuven University Vaccinology Centre, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Nele Vanmechelen
- grid.5596.f0000 0001 0668 7884Department of Endocrinology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Bart Van der Schueren
- grid.5596.f0000 0001 0668 7884Department of Endocrinology, University Hospitals Leuven, KU Leuven, Leuven, Belgium ,grid.5596.f0000 0001 0668 7884Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Isabelle Huys
- grid.5596.f0000 0001 0668 7884Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| |
Collapse
|
4
|
Kantasiripitak W, Outtier A, Wicha SG, Kensert A, Wang Z, Sabino J, Vermeire S, Thomas D, Ferrante M, Dreesen E. Multi‐model averaging improves the performance of model‐guided infliximab dosing in patients with inflammatory bowel diseases. CPT Pharmacometrics Syst Pharmacol 2022; 11:1045-1059. [PMID: 35706358 PMCID: PMC9381887 DOI: 10.1002/psp4.12813] [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: 04/08/2022] [Revised: 04/08/2022] [Accepted: 05/05/2022] [Indexed: 11/11/2022] Open
Abstract
Infliximab dosage de‐escalation without prior knowledge of drug concentrations may put patients at risk for underexposure and trigger the loss of response. A single‐model approach for model‐informed precision dosing during infliximab maintenance therapy has proven its clinical benefit in patients with inflammatory bowel diseases. We evaluated the predictive performances of two multi‐model approaches, a model selection algorithm and a model averaging algorithm, using 18 published population pharmacokinetic models of infliximab for guiding dosage de‐escalation. Data of 54 patients with Crohn’s disease and ulcerative colitis who underwent infliximab dosage de‐escalation after an earlier escalation were used. A priori prediction (based solely on covariate data) and maximum a posteriori prediction (based on covariate data and trough concentrations) were compared using accuracy and precision metrics and the classification accuracy at the trough concentration target of 5.0 mg/L. A priori prediction was inaccurate and imprecise, with the lowest classification accuracies irrespective of the approach (median 59%, interquartile range 59%–63%). Using the maximum a posteriori prediction, the model averaging algorithm had systematically better predictive performance than the model selection algorithm or the single‐model approach with any model, regardless of the number of concentration data. Only a single trough concentration (preferably at the point of care) sufficed for accurate and precise prediction. Predictive performance of both single‐ and multi‐model approaches was robust to the lack of covariate data. Model averaging using four models demonstrated similar predictive performance with a five‐fold shorter computation time. This model averaging algorithm was implemented in the TDMx software tool to guide infliximab dosage de‐escalation in the forthcoming prospective MODIFI study (NCT04982172).
Collapse
Affiliation(s)
- Wannee Kantasiripitak
- Department of Pharmaceutical and Pharmacological Sciences University of Leuven Leuven Belgium
| | - An Outtier
- Department of Gastroenterology and Hepatology University Hospitals Leuven Leuven Belgium
- Department of Chronic Diseases and Metabolism University of Leuven Leuven Belgium
| | - Sebastian G. Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy University of Hamburg Hamburg Germany
| | - Alexander Kensert
- Department of Pharmaceutical and Pharmacological Sciences University of Leuven Leuven Belgium
- Department of Chemical Engineering Vrije Universiteit Brussels Brussels Belgium
| | - Zhigang Wang
- Department of Pharmaceutical and Pharmacological Sciences University of Leuven Leuven Belgium
| | - João Sabino
- Department of Gastroenterology and Hepatology University Hospitals Leuven Leuven Belgium
- Department of Chronic Diseases and Metabolism University of Leuven Leuven Belgium
| | - Séverine Vermeire
- Department of Gastroenterology and Hepatology University Hospitals Leuven Leuven Belgium
- Department of Chronic Diseases and Metabolism University of Leuven Leuven Belgium
| | - Debby Thomas
- Department of Pharmaceutical and Pharmacological Sciences University of Leuven Leuven Belgium
| | - Marc Ferrante
- Department of Gastroenterology and Hepatology University Hospitals Leuven Leuven Belgium
- Department of Chronic Diseases and Metabolism University of Leuven Leuven Belgium
| | - Erwin Dreesen
- Department of Pharmaceutical and Pharmacological Sciences University of Leuven Leuven Belgium
| |
Collapse
|
5
|
Verstockt B, Volk V, Jaeckel C, Alsoud D, Sabino J, Nikolaus S, Outtier A, Krönke N, Feuerhake F, De Hertogh G, Rosenstiel P, Vermeire S, Schreiber S, Ferrante M, Aden K. Longitudinal monitoring of STAT3 phosphorylation and histologic outcome of tofacitinib therapy in patients with ulcerative colitis. Aliment Pharmacol Ther 2022; 56:282-291. [PMID: 35484689 DOI: 10.1111/apt.16955] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 02/12/2022] [Revised: 03/25/2022] [Accepted: 04/20/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Tofacitinib is the first in class, pan-JAK inhibitor approved for ulcerative colitis (UC). Clinical efficacy has been shown, but long-term real-life endoscopic and histologic data are lacking. AIM To investigate the effects of tofacitinib in patients with refractory UC focussing on endoscopic, histologic and molecular outcomes, including STAT3 phosphorylation (pSTAT3) detection in the spatial context of mucosal inflammation METHODS: We prospectively monitored 59 highly refractory patients (96.7% anti-TNF exposure, 91.7% vedolizumab exposure) initiating tofacitinib at two IBD referral centres and assessed outcome at the end of induction and after 48 weeks of therapy. Endoscopic improvement was defined as a Mayo endoscopic subscore ≤1, endoscopic and histologic remission as Mayo endoscopic subscore 0 and Nancy histologic score 0. Multiplex immunohistochemistry with multispectral imaging was used to assess pSTAT3. RESULTS Endoscopic improvement was achieved by 24.4% and 30.5% of patients at weeks 8 and 48, respectively. Endoscopic and histologic remission rates were 11.1%, 23.7 and 16.7%, 21.4%, respectively. Endoscopic improvement at week 8 was significantly associated with treatment continuation in the long-term (72.7% vs 20.6%, p = 0.003). Although we observed a gradual decrease of mucosal pSTAT3 levels in both remitters and non-remitters (p < 0.05), no association with treatment outcome could be demonstrated. However, lamina propria pSTAT3 was significantly associated with the Nancy Histologic index (p = 0.004). CONCLUSION Tofacitinib can induce and maintain endoscopic and histologic remission in up to one-quarter of highly refractory UC patients. Longitudinal monitoring of nuclear pSTAT3 in mucosal tissue compartments reflects distinctive on-target effects, independently of long-term treatment outcomes.
Collapse
Affiliation(s)
- Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium.,Translational Research in Gastrointestinal Disorders, Department of Chronic Disease, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Valery Volk
- Institute for Pathology, Hannover Medical School, Hannover, Germany
| | - Charlot Jaeckel
- Institute of Clinical Molecular Biology, Christian-Albrechts-University and University Hospital Schleswig-Holstein, Kiel, Germany
| | - Dahham Alsoud
- Translational Research in Gastrointestinal Disorders, Department of Chronic Disease, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - João Sabino
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium.,Translational Research in Gastrointestinal Disorders, Department of Chronic Disease, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Susanna Nikolaus
- Department of Internal Medicine I, Christian-Albrechts-University and University Hospital Schleswig-Holstein, Kiel, Germany
| | - An Outtier
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Nicole Krönke
- Institute for Pathology, Hannover Medical School, Hannover, Germany
| | | | - Gert De Hertogh
- Laboratory of Morphology and Molecular Pathology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Philip Rosenstiel
- Institute of Clinical Molecular Biology, Christian-Albrechts-University and University Hospital Schleswig-Holstein, Kiel, Germany.,Department of Internal Medicine I, Christian-Albrechts-University and University Hospital Schleswig-Holstein, Kiel, Germany
| | - Séverine Vermeire
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium.,Translational Research in Gastrointestinal Disorders, Department of Chronic Disease, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Stefan Schreiber
- Institute of Clinical Molecular Biology, Christian-Albrechts-University and University Hospital Schleswig-Holstein, Kiel, Germany.,Department of Internal Medicine I, Christian-Albrechts-University and University Hospital Schleswig-Holstein, Kiel, Germany
| | - Marc Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium.,Translational Research in Gastrointestinal Disorders, Department of Chronic Disease, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Konrad Aden
- Institute of Clinical Molecular Biology, Christian-Albrechts-University and University Hospital Schleswig-Holstein, Kiel, Germany.,Department of Internal Medicine I, Christian-Albrechts-University and University Hospital Schleswig-Holstein, Kiel, Germany
| |
Collapse
|
6
|
Goessens L, Colombel JF, Outtier A, Ferrante M, Sabino J, Judge C, Saeidi R, Rabbitt L, Armuzzi A, Domenech E, Michalopoulos G, Cremer A, García-Alonso FJ, Molnar T, Karmiris K, Gecse K, Van Oostrom J, Löwenberg M, Farkas K, Atreya R, Ribaldone DG, Selinger C, Hoentjen F, Bihin B, Sebastian S, Rahier JF. Safety and efficacy of combining biologics or small molecules for inflammatory bowel disease or immune-mediated inflammatory diseases: A European retrospective observational study. United European Gastroenterol J 2021; 9:1136-1147. [PMID: 34694746 PMCID: PMC8672088 DOI: 10.1002/ueg2.12170] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 09/22/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND AND AIMS Few data are available regarding the combination of biologics or small molecules in inflammatory bowel disease (IBD) patients. We report safety and efficacy of such combinations through a retrospective multicentre series. METHODS Combination therapy was defined as the concomitant use of two biologics or one biologic with a small molecule. Patient demographics, disease characteristics and types of combinations were recorded. Safety was evaluated according to the occurrence of serious infection, opportunistic infection, hospitalisation, life-threatening event, worsening of IBD or immune-mediated inflammatory diseases (IMID), cancer and death. Efficacy was evaluated as the physician global assessment of the combination and comparison of clinical/endoscopic scores of IBD/IMID activity prior and during combination. RESULTS A total of 104 combinations were collected in 98 patients. Concomitant IMID were present in 41 patients. Reasons for starting combination therapy were active IBD (67%), active IMID or extra-intestinal manifestations (EIM) (22%), both (10%) and unclassified in 1. Median duration of combination was 8 months (interquartile range 5-16). During 122 patient-years of follow-up, 42 significant adverse events were observed, mostly related to uncontrolled IBD. There were 10 significant infections, 1 skin cancer and no death. IBD disease activity was clinically improved in 70% and IMID/EIM activity in 81% of the patients. Overall, combination was continued in 55% of the patients. CONCLUSIONS Combination of biologics and small molecules in patients with IBD and IMID/EIM seems to be a promising therapeutic strategy but is also associated with a risk of opportunistic infections or infections leading to hospitalisation in 10%.
Collapse
Affiliation(s)
- Laurent Goessens
- Department of Gastroenterology and Hepatology, Centre Hospitalier Universitaire UCL Namur, Yvoir, Belgium
| | | | - An Outtier
- Department of Gastroenterology and Hepatology, KU Leuven, University Hospital Leuven, Leuven, Belgium
| | - Marc Ferrante
- Department of Gastroenterology and Hepatology, KU Leuven, University Hospital Leuven, Leuven, Belgium
| | - Joao Sabino
- Department of Gastroenterology and Hepatology, KU Leuven, University Hospital Leuven, Leuven, Belgium
| | - Ciaran Judge
- Department of Gastroenterology, INITIative IBD Research Network, Mercy University Hospital, Cork, Ireland
| | - Reza Saeidi
- Centre for Colorectal Disease, INITIative IBD Research Network, St Vincent's University Hospital & School of Medicine, University College Dublin, Dublin, Ireland
| | - Louise Rabbitt
- Department of Clinical Pharmacology and Therapeutics, INITIative IBD research network, Galway University Hospital, Galway, Ireland
| | - Alessandro Armuzzi
- IBD Center, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Eugeni Domenech
- Gastroenterology Department, Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - George Michalopoulos
- Gastroenterology Department, General Hospital of Piraeus 'Tzaneio', Piraeus, Greece
| | - Anneline Cremer
- Department of Gastroenterology, Erasme University Hospital, Brussels, Belgium
| | | | - Tamas Molnar
- Gastroenterology Unit, First Department of Medicine, University of Szeged, Szeged, Hungary
| | | | - Krisztina Gecse
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Joep Van Oostrom
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Mark Löwenberg
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Klaudia Farkas
- Gastroenterology Unit, First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Raja Atreya
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | | | | | - Frank Hoentjen
- Department of Gastroenterology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Benoit Bihin
- Department of Statistics, Centre Hospitalier Universitaire UCL Namur, Yvoir, Belgium
| | | | | | - Jean-François Rahier
- Department of Gastroenterology and Hepatology, Centre Hospitalier Universitaire UCL Namur, Yvoir, Belgium
| |
Collapse
|
7
|
Abstract
Background Pouchitis is the most common long-term complication in patients with ulcerative colitis who underwent restorative proctocolectomy with ileal pouch-anal anastomosis. The incidence of acute pouchitis is 20% after 1 year and up to 40% after 5 years. Chronic antibiotic-refractory pouchitis develops in approximately 10% of patients. Aim To present a narrative review of published literature regarding the management of chronic antibiotic-refractory pouchitis. Methods Current relevant literature was summarized and critically evaluated. Results Clear definitions should be used to classify pouchitis into acute versus chronic, and responsive versus dependent versus refractory to antibiotics. Before treatment is started for chronic antibiotic-refractory pouchitis, secondary causes should be ruled out. There is a need for validated scoring systems to measure the severity of the disease. Because chronic antibiotic-refractory pouchitis is a rare condition, only small studies with often a poor study design have been performed. Treatments with antibiotics, aminosalicylates, steroids, immunomodulators and biologics have shown to be effective and safe for chronic antibiotic-refractory pouchitis. Also, treatments with AST-120, hyperbaric oxygen therapy, tacrolimus enemas, and granulocyte and monocyte apheresis suggested some efficacy. Conclusion The available data are weak but suggest that therapeutic options for chronic antibiotic-refractory pouchitis are similar to the treatment strategies for inflammatory bowel diseases. However, randomized controlled trials are warranted to further identify the best treatment options in this patient population.
Collapse
Affiliation(s)
- An Outtier
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Marc Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| |
Collapse
|
8
|
Carels C, Wauters L, Outtier A, Baert F, Bossuyt P, Colard A, De Looze D, Ferrante M, Goegebuer A, Hauser B, Hilbrands R, Hoffman I, Keymeulen B, Paquot I, Ruytjens I, Simoens M, Thienpont C, Verreth A, Verstockt B, Vermeire S, Veereman G. Health Literacy and Quality of Life in Young Adults From The Belgian Crohn's Disease Registry Compared to Type 1 Diabetes Mellitus. Front Pediatr 2021; 9:624416. [PMID: 33614555 PMCID: PMC7892785 DOI: 10.3389/fped.2021.624416] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 01/11/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Aims: The management of chronic inflammatory bowel diseases in youth is challenging. We aimed to determine health literacy (HL), quality of life (QoL) and clinical outcomes in young adults from the BELgian CROhn's disease registry (BELCRO) in comparison to type 1 diabetes mellitus (DM) as a control. Methods: In this prospective and observational study, young adults with Crohn's disease (CD) diagnosed < 18 years and with > 5 years disease duration and a comparable group of patients with DM completed validated HL, QoL and work productivity and activity impairment questionnaires (HLS-EU-Q16, EQ-5D-5L and WPAI). HL was scored as sufficient (13-16), problematic (9-12) or inadequate (0-8). QoL was dichotomized into "no problems" (EQ-5D level 1) or "problems" (EQ-5D levels 2 to 5). Non-parametric (Mann-Whitney U) analyses and Spearman correlations were performed. Results: A total of 52 CD (median [IQR] age of 25.0 [23.8-27.0], 64% male) and 50 DM (age 20.0 [19.0-22.0], 50% male) patients were included. HL was 14.0 [11.0-16.0] for CD and 14.0 [11.3-14.8] for DM (p = 0.6) with similar proportions of sufficient (60 vs. 68%, p = 0.4), problematic (34 vs. 26%, p = 0.3) and inadequate HL (both 6%, p = 1). Although QoL was comparable for CD and DM (77.0 [68.8-82.0] vs. 75.0 [65.0-80.0] %, p =0.4), CD had a trend for higher pain/discomfort (50 vs. 32%, p = 0.06). HL and QoL correlated in CD (r = 0.6, p < 0.001) and DM patients (r = 0.6, p < 0.001). Fewer CD patients with recent hospitalization/surgery had sufficient HL (31 vs. 69%, p = 0.01) and had lower QoL (70.0 [60.0-77.0] vs. 80.0 [70.0-85.0], p = 0.04) compared to those without. Conclusions: Selected young Belgian adults suffering from CD for >5 years have similar and sufficient HL compared to DM patients. However, CD patients requiring hospitalization/surgery have lower HL, which indicates the need for targeted educational programs.
Collapse
Affiliation(s)
| | - Lucas Wauters
- Gastroenterology and Hepatology, University Hospitals, KU Leuven, Leuven, Belgium
| | - An Outtier
- Gastroenterology and Hepatology, University Hospitals, KU Leuven, Leuven, Belgium
| | - Filip Baert
- Gastroenterology, AZ Delta, Roeselare, Belgium
| | - Peter Bossuyt
- Gastroenterology, Imelda Ziekenhuis, Bonheiden, Belgium
| | | | - Danny De Looze
- Gastroenterology and Hepatology, UZ Gent, Ghent, Belgium
| | - Marc Ferrante
- Gastroenterology and Hepatology, University Hospitals, KU Leuven, Leuven, Belgium
| | | | - Bruno Hauser
- Pediatric Gastroenterology, UZ Brussels, Jette, Belgium
| | | | - Ilse Hoffman
- Pediatric Gastroenterology, University Hospitals, KU Leuven, Leuven, Belgium
| | | | | | | | - Marc Simoens
- Gastroenterology, ZNA Jan Palfijn, Merksem, Belgium
| | | | | | - Bram Verstockt
- Gastroenterology and Hepatology, University Hospitals, KU Leuven, Leuven, Belgium
| | - Séverine Vermeire
- Gastroenterology and Hepatology, University Hospitals, KU Leuven, Leuven, Belgium
| | - Gigi Veereman
- Pediatric Gastroenterology, UZ Brussels, Jette, Belgium
| |
Collapse
|
9
|
Verstockt B, Van Hemelen M, Outtier A, Sabino J, Van Wijngaerden E, De Munter P, Ferrante M, Wilmer A, Vermeire S. Invasive nocardiosis, disseminated varicella zoster reactivation, and pneumocystis jiroveci pneumonia associated with tofacitinib and concomitant systemic corticosteroid use in ulcerative colitis. J Gastroenterol Hepatol 2020; 35:2294-2297. [PMID: 32918841 DOI: 10.1111/jgh.15256] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 05/05/2020] [Revised: 08/30/2020] [Accepted: 09/07/2020] [Indexed: 12/22/2022]
Affiliation(s)
- B Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.,KU Leuven Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders (TARGID), Leuven, Belgium
| | - M Van Hemelen
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - A Outtier
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - J Sabino
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.,KU Leuven Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders (TARGID), Leuven, Belgium
| | - E Van Wijngaerden
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - P De Munter
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - M Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.,KU Leuven Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders (TARGID), Leuven, Belgium
| | - A Wilmer
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - S Vermeire
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.,KU Leuven Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders (TARGID), Leuven, Belgium
| |
Collapse
|
10
|
Verstockt B, Mertens E, Dreesen E, Outtier A, Noman M, Tops S, Schops G, Van Assche G, Vermeire S, Gils A, Ferrante M. Influence of Drug Exposure on Vedolizumab-Induced Endoscopic Remission in Anti-Tumour Necrosis Factor [TNF] Naïve and Anti-TNF Exposed IBD Patients. J Crohns Colitis 2020; 14:332-341. [PMID: 31504343 DOI: 10.1093/ecco-jcc/jjz151] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [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 OBJECTIVES Vedolizumab has demonstrated efficacy and safety in patients with Crohn's disease [CD] and ulcerative colitis [UC]. Endoscopic outcome data are limited, especially in anti-tumour necrosis factor [TNF] naïve patients. The present study compared endoscopic outcome in anti-TNF naïve and exposed patients, and explored if this was affected by drug exposure. METHODS We retrospectively analysed all patients initiating vedolizumab at our tertiary referral centre since 2015. For UC, endoscopic improvement was defined as a Mayo endoscopic subscore ≤1 at week 14. For CD, endoscopic remission was defined as absence of ulcerations at week 22. Vedolizumab trough concentrations were measured at week 6, week 14 and during maintenance. RESULTS A total of 336 patients were identified [53.3% CD], 20% of them being anti-TNF naïve. Endoscopic improvement was achieved by 56.1% of UC patients and endoscopic remission by 39.1% of CD patients. Endoscopic outcomes were significantly better in anti-TNF naïve vs exposed patients [all: 67.2% vs 42.0%, p = 0.0002; UC: 74.4% vs 50.0%, p = 0.02; CD: 57.1% vs 35.8%, p = 0.03]. Achievement of endoscopic end points significantly impacted long-term treatment continuation [p = 9.7 × 10-13]. A better endoscopic outcome was associated with significantly higher drug exposure in both CD and UC. CONCLUSIONS The results of this observational, single-centre real-life study suggest that vedolizumab may induce endoscopic remission in both CD and UC. Although anti-TNF naïve patients had a significantly better outcome, 42% of anti-TNF exposed patients still benefited endoscopically. A clear exposure-endoscopic response relationship exists, but not all patients will benefit from treatment intensification. Hence, predictive biomarkers remain necessary. PODCAST This article has an associated podcast which can be accessed at https://academic.oup.com/ecco-jcc/pages/podcast.
Collapse
Affiliation(s)
- Bram Verstockt
- University Hospitals Leuven, Department of Gastroenterology and Hepatology, KU Leuven, Leuven, Belgium.,KU Leuven Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders (TARGID), Leuven, Belgium
| | - Evelien Mertens
- University Hospitals Leuven, Department of Gastroenterology and Hepatology, KU Leuven, Leuven, Belgium
| | - Erwin Dreesen
- KU Leuven Department of Pharmaceutical and Pharmacological Sciences, Laboratory for Therapeutic and Diagnostic Antibodies
| | - An Outtier
- University Hospitals Leuven, Department of Gastroenterology and Hepatology, KU Leuven, Leuven, Belgium
| | - Maja Noman
- University Hospitals Leuven, Department of Gastroenterology and Hepatology, KU Leuven, Leuven, Belgium
| | - Sophie Tops
- KU Leuven Department of Pharmaceutical and Pharmacological Sciences, Laboratory for Therapeutic and Diagnostic Antibodies
| | - Ganel Schops
- University Hospitals Leuven, Department of Gastroenterology and Hepatology, KU Leuven, Leuven, Belgium
| | - Gert Van Assche
- University Hospitals Leuven, Department of Gastroenterology and Hepatology, KU Leuven, Leuven, Belgium.,KU Leuven Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders (TARGID), Leuven, Belgium
| | - Séverine Vermeire
- University Hospitals Leuven, Department of Gastroenterology and Hepatology, KU Leuven, Leuven, Belgium.,KU Leuven Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders (TARGID), Leuven, Belgium
| | - Ann Gils
- KU Leuven Department of Pharmaceutical and Pharmacological Sciences, Laboratory for Therapeutic and Diagnostic Antibodies
| | - Marc Ferrante
- University Hospitals Leuven, Department of Gastroenterology and Hepatology, KU Leuven, Leuven, Belgium.,KU Leuven Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders (TARGID), Leuven, Belgium
| |
Collapse
|
11
|
Verstockt B, Dreesen E, Noman M, Outtier A, Van den Berghe N, Aerden I, Compernolle G, Van Assche G, Gils A, Vermeire S, Ferrante M. Ustekinumab Exposure-outcome Analysis in Crohn's Disease Only in Part Explains Limited Endoscopic Remission Rates. J Crohns Colitis 2019; 13:864-872. [PMID: 30715258 DOI: 10.1093/ecco-jcc/jjz008] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 12/30/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Ustekinumab, an anti-IL12/23p40 monoclonal antibody, has been approved for Crohn's disease [CD]. Real-life data in CD patients receiving ustekinumab intravenously [IV] during induction, followed by subcutaneous [SC] maintenance, are lacking. We assessed efficacy of ustekinumab and studied exposure-response correlations. METHODS We performed a prospective study in 86 CD patients predominantly refractory or intolerant to anti-tumour necrosis factor agents and/or vedolizumab. All received ustekinumab 6 mg/kg IV induction, with 90 mg SC every 8 weeks thereafter. Endoscopic response (50% decrease in Simple Endoscopic Score for CD [SES-CD] at Week 24), endoscopic remission [SES-CD ≤2], and clinical remission [daily stool frequency ≤2.8 and abdominal pain score ≤1] were assessed at weeks 4,8,16, and 24. Further serial analyses included patient-reported outcomes [PRO2], faecal calprotectin [fCal], and ustekinumab serum levels. RESULTS SES-CD decreased from 11.5 [8.0-18.0] at baseline to 9.0 [6.0-16.0] at week [w]24 [p = 0.0009], but proportions of patients achieving endoscopic response [20.5%] or endoscopic remission [7.1%] were low. Clinical remission rates were 39.5% at w24. After IV induction, fCal dropped from baseline [1242.9 μg/g] to w4 [529.0 μg/g] and w8 [372.2 μg/g], but increased again by w16 [537.4 μg/g] and w24 [749.0 μg/g]. A clear exposure-response relationship was observed, both during induction and during maintenance therapy, with different thresholds depending on the targeted outcome. CONCLUSIONS In this cohort of refractory CD patients, ustekinumab showed good clinical remission rates but limited endoscopic remission after 24 weeks. Our data suggest that higher doses may be required to achieve better endoscopic outcomes.
Collapse
Affiliation(s)
- Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Erwin Dreesen
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Maja Noman
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - An Outtier
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | | | - Isolde Aerden
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Griet Compernolle
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Gert Van Assche
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Ann Gils
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Séverine Vermeire
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Marc Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| |
Collapse
|