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Immunomodulators and Biologics

Immunomodulators and Biologics. Maria T. Abreu, MD University of Miami Miller School of Medicine Miami, Florida. Management of Post-Operative Recurrence of IBD. David T. Rubin, MD, AGAF Associate Professor of Medicine Co-Director, Inflammatory Bowel Disease Center

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Immunomodulators and Biologics

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  1. Immunomodulators and Biologics Maria T. Abreu, MD University of Miami Miller School of Medicine Miami, Florida

  2. Management of Post-Operative Recurrence of IBD David T. Rubin, MD, AGAF Associate Professor of Medicine Co-Director, Inflammatory Bowel Disease Center University of Chicago Medicine

  3. Maintenance of remission off steroids and/or Mucosal healing (histology) Induction of remission IBD Maintenance of remission

  4. What do we know: Guiding principles Combination therapy is better than monotherapy Early therapy is better than late therapy (esp Crohn’s disease) Well timed surgery is ok

  5. Indications for Surgery • Crohn’s disease: • Obstruction • Medically refractory disease • Hemorrhage/transfusion requirements • High grade dysplasia or cancer • Growth delay • Fistula/abscess • Ulcerative colitis: • Medically refractory disease/fulminant disease • High grade dysplasia or cancer • Hemorrhage/transfusion requirements • Perforation

  6. Mouse Human PEG, polyethylene glycol. First-line Biologic Agents for the Treatment of CD Certolizumab Pegol Infliximab Adalimumab VL VH CH1 No Fc PEG IgG1 IgG1 PEG Human recombinant antibody (100% humanIgG1 isotype) Chimeric monoclonal antibody (75% humanIgG1 isotype) Humanized Fab’fragment (95% humanIgG1 isotype)

  7. SONIC • Moderate-to-severe CD in patients with no prior exposure to biologic agents or immunomodulators • Excluded intermediate TPMT activity • Average disease duration 2.3 years AZA 2.5mg/kg IFX 5mg/kg IFX + AZA • 1° endpoint: Induction + maintenance of steroid-free remission • 2° endpoint: Mucosal healing

  8. 9 SONIC Clinical Remission Without Corticosteroids at Week 26 Primary Endpoint 100 p<0.001 80 p=0.009 p=0.022 57 60 Proportion of Patients (%) 45 40 30 20 52/170 75/169 96/169 0 AZA + placebo IFX + placebo IFX+ AZA Colombel, J.F., et al., N Engl J Med. 362(15): p. 1383-95.

  9. Cumulative Probability of Surgeryin Crohn’s Disease 100 80 60 Patients* (%) 40 20 0 0 5 10 15 20 25 30 35 Years After Onset Mekhjian HS et al. Gastroenterol. 1979;77(4 pt 2):907-913.

  10. Preoperative Corticosteroids Increase Risk of Postoperative Complications in IBD *Major complications include sepsis, pneumonia, peritonitis, abscess, wound infection • 159 IBD patients (71 UC, 88 CD) undergoing elective bowel surgery CS, corticosteroids; 6-MP, 6-mercaptopurine; AZA, azathioprine Aberra FN et al. Gastroenterology. 2003;125:320.

  11. Postoperative infections CD1: Mayo Clinic 52 IFX vs 218 no IFX OR 0.9 (95% CI 0.4–1.9)1 UC2: Mayo Clinic 47 IFX vs. 254 no IFX OR 2.7 (95% CI 1.1–6.7) UC3: Cleveland Clinic Pelvic sepsis 46 IFX vs. 46 no IFX OR 13.8 (1.8–105) TNF Use Prior to Surgery CD ? UC 1. Colombel JF et al. Am J Gastroenterol. 2004;99:878. 2. Selvasekar CR et al. J Am Coll Surg. 2007;204:956. 3. Mor IJ. Dis Col Rectum. 2008;51:1202. IFX, infliximab; OR, odds ratio; CI, confidence interval

  12. SymptomaticInflammation SubclinicalInflammation Disability Health Post-op Ileocecectomy is the Perfect Opportunity for Prevention! Complications DiseasePrevention Prevention ofComplications Prevention ofSymptomatic Disease Prevention ofRelapse

  13. Recurrence After Surgery in Crohn’s Disease 100 N=89 80 Survival without surgery Survival withoutlaboratory recurrence 60 Patients (%) Survival without symptoms 40 Survival withoutendoscopic lesions 20 0 0 1 2 3 4 5 6 7 8 Years Rutgeerts P et al. Gastroenterol. 1990;99(4):956-963.

  14. Risk Stratification for Recurrence in Post-operative Crohn’s disease • Smoking • Perforating-type of disease • Small bowel disease • Ileocolonic disease • Perianal fistulas • Duration of disease • Age • ? Clear margins • ? Length of resection • ?Type of anastomosis Greenstein AJ et al. Gut. 1988;29(5):588-592. Bernell O et al. Ann Surg. 2000;231(1):38-45. Bernell O et al. Br J Surg. 2000;87(12):1697-1701. D'Haens GR et al. Gut. 1995;36(5):715-717. Lautenbach E et al. Gastroenterol.1998;115(2):259-267. Moskovitz D et al. Int J Colorectal Dis. 1999;14(4-5):224-226. Kono T et al. Dis Colon Rectum2011 May;54(5):586-92.

  15. The Neo-TI: The Rutgeerts’ ScorePatients should be scoped 6 months after surgery to re-stratify risk Rutgeerts 0 Rutgeerts 1 Rutgeerts 2 Normal ileal mucosa <5 aphthous ulcers >5 aphthous ulcers, normal intervening mucosa Ulceration without normal intervening mucosa Severe ulceration with nodules, cobblestoning, or stricture Rutgeerts 3 Rutgeerts 4

  16. The neo-terminal ileum is not the anastomosis! • Suture-related trauma • Marginal ulcerations/ischemia

  17. Symptoms after Crohn’s Surgery are Not Always Inflammatory!

  18. Medical Prevention of Clinical and Endoscopic Recurrence of Crohn’s Disease Regueiro M. Inflamm Bowel Dis. 2009 Oct;15(10):1583-90.

  19. Thiopurines for the prevention of postoperative recurrence in Crohn’s disease: meta-analysis Endoscopic Clinical Peyrin-Biroulet L et al. Am J Gastroenterol. 2009 Aug;104(8):2089-96.

  20. Metronidazole/azathioprine combination therapy for post-operative recurrence High risk pts (n=81) = (age <30, smokers, steroids <3 months, second resection, perforated/abscess) N=40 metronidazole 250 mg TID 3 months + AZA 2–3 tabs N=41 metronidazole 250 mg TID 3 months + placebo % patients with endoscopic recurrence (>i2) post surgery D'Haens GR et al.Gastroenterology. 2008 Oct;135(4):1123-9.

  21. Post-operative Endoscopic RecurrenceInfliximab vs. Placebo Infliximab vs placebop=0.0006 1/11 11/13 Endoscopic Recurrence defined as endoscopic scores of i2, i3, or i4. Regueiro M et al. 2009 Feb;136(2):441-50.e1; quiz 716.

  22. Proposed Algorithm for Prevention of Post-Op Recurrence in Crohn’s Assess risk of recurrence Low Moderate High Don’t Know Therapy? Start therapy Start therapy ? Metronidazole at discharge Metronidazole at discharge 4 weeks 4 weeks Thiopurine + MTX TNF + IMM Colonoscopy at 6 months Colonoscopy at 6 months Colonoscopy at 6 months Colonoscopy at 3-6 months i2-i4 i0-i1 i2-i4 i0-i1 i0-i1 i2-i4 Treatment Escalate Rx Change dose/ optimization Follow up

  23. Ulcerative colitis

  24. ACT 1 and ACT 2 Early mucosal healing a favorable prognostic factor in UC Infliximab-treated patients P<0.0001 Week 8 endoscopy Patients in Corticosteroid-free remission % Week 8 endoscopic score Colombel JF et al. Gastroenterology. 2011 Jun 29. [Epub ahead of print].

  25. Can Surgery for UC be Prevented?Mucosal Healing and Time to Colectomy in Infliximab-Treated Patients 0 = NORMAL 1 = MILD 2 = MODERATE 3 = SEVERE Colombel JF, Rutgeerts P, Reinisch W, et al. Gastroenterology. 2011 Oct;141(4):1194-201

  26. Ulcerative Colitis: Ileo-pouch Anal Anastomosis Colectomy Cuff/Anal Transition zone J pouch

  27. Better Outcomes at High Volume Hospitals 50 OR = 1.18 (0.99–1.41) Percent 40 35.4 30 25.6 20 OR = 2.42 (1.26–4.63) 10 Mortality Complications 4.0 0.7 0 High volume Low volume Kaplan GG et al. Gastroenterology. 2008;134:680.

  28. “Complications” of the Ileal Pouch Surgical/ Mechanical Inflammatory/ Infectious Functional Dysplasia/ Neoplasia Systemic/ Metabolic • Pouchitis • Crohn’s dis. • Cuffitis • Small • bowel bacterial • overgrowth • CMV • C. difficile • Polyps • Irritable • pouch syn. • Pelvic floor • dysfunction • Poor pouch • compliance • Pseudo- • obstruction • Afferent limb syn. • Efferent limb syn. • Strictures • - Leaks • Fistulae • Sinuses • - Abscess • Adhesions • Re-operation • Anemia • Osteoporosis • Vitamin B12 • deficiency • Malnutrition • Fertility • Sexuality • Dysplasia • Cancer Compliments of Bo Shen, MD

  29. Risk Factors for Pouchitis • Extensive UC • Backwash ileitis • Primary sclerosing cholangitis • p-ANCA • NOD2/ IL-1 receptor antagonist polymorphisms • Ex-smoker • NSAIDs • Arthralgias • Family history of Crohn’s disease Fazio VW et al. Ann Surg. 1995 August; 222(2): 120–127; Schmidt CM et al. Ann Surg. 1998 May; 227(5): 654–665; J L Lohmuller et al.Ann Surg. 1990 May; 211(5): 622–629; Fleshner P et al.Clin Gastroenterol Hepatol. 2007 Aug;5(8):952-8; quiz 887; Achkar JP et al.Clin Gastroenterol Hepatol. 2005 Jan;3(1):60-6; Shen B et al. Am J Gastroenterol. 2005 Jan;100(1):93-101; Le Q et al. Inflamm Bowel Dis. 2012 Mar 29 [Epub ahead of print]

  30. Figure: http://www.webmd.com accessed May, 2012.

  31. Management of Pouchitis (endoscopic confirmation is preferred) Pouchitis Cipro or Metronidazole x 2 wks Responded Not Responded Cipro or Metronidazole x 2 more wks Infrequent Relapse Frequent Relapse Responded Not Responded Antbx-responsive Pouchitis Antbx-dependent Pouchitis Antbx-refractory Pouchitis Cipro+ Metronidazole or Rifaximin or Tinidazole x 4 wks Antibiotics prn Probiotics or Antibiotics Not Responded 5-ASA/steroids/ Immunomodulators/Infliximab?

  32. Can Pouchitis be Prevented? Frequency of Pouchitis with Probiotic Prophylaxis P < 0.05 % cases with flare-up N = 20 6 grams QD x 12 months N = 20 Gionchetti P et al. Gastroenterol2003 May;124(5):1202-9.

  33. Key Take Home Messages

  34. IBD • Stratify patients for disease severity & potential long-term complications • Combination therapy better than monotherapy for sick patients naïve to both • Low Absolute risk of IS or Biologic therapy • Vaccines, DXAs and other health maintenance issues will eventually be used to measure quality

  35. Risks of IBD Therapy • Non-melanoma skin cancer (NMSC) associated with current or past IS therapy • No other solid tumors show clear association with IS or anti-TNF therapy • No clear signal that combination therapy leads to higher risk than monotherapy • HSTCL occurs AFTER 2 years of thiopurine exposure • Risk of PML after 2 years on natalizumab about 1 in 100 exposed patients

  36. Management of Post-operative Recurrence in IBD • Know patient’s risk of recurrence • Confirm endoscopic disease • Ulcerative colitis • Mucosal healing reduces risk of colectomy • Assess risk of pouchitis • Distinguish pouchitis/Crohn’s/pre-pouch ileitis • Crohn’s disease (ileo-colonic anastomosis) • Assess colonoscopic recurrence @ 6 months • Prophylaxis vs re-treatment based on risks and treatment history • Subsequent clinical/endoscopic f/u not defined

  37. Microscopic colitis • Incidence appears to have stabilized • Consider celiac disease if steatorrhea or weight loss • Consider drug-induced MC • Treat with bismuth or budesonide • -Right dose and right duration • Maintenance therapy with budesonide is effective

  38. Gut microbiota and IBS • Microbiota in IBS: • Differs from health & may contribute to pathogenesis • May lead novel diagnostic tests for IBS • May select or predict response to IBS treatments treatments • Provide potential target in IBS • Antibiotics, Probiotics, Therapeutic foods

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