Optimization of the treatment with immunosuppressants and biologics in inflammatory bowel disease
Sara Renna, Mario Cottone, Ambrogio Orlando
Sara Renna, Mario Cottone, Ambrogio Orlando, Division of Internal Medicine, ‘‘Villa Sofia-V. Cervello’’ Hospital, 90146 Pal- ermo, Italy
Author contributions: Renna S, Cottone M and Orlando A de- signed and wrote the introductory editorial for the Topic Highlights. Correspondence to: Sara Renna, MD, Division of Internal Medicine, ‘‘Villa Sofia-V. Cervello’’ Hospital, 90146 Palermo, Italy.
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Telephone: +39-091-6802966 Fax: +39-091-6802042 Received: October 29, 2013 Revised: January 18, 2014 Accepted: April 28, 2014
Published online: August 7, 2014
Abstract
Many placebo controlled trials and meta-analyses evalu- ated the efficacy of different drugs for the treatment of inflammatory bowel disease (IBD), including immu- nosuppressants and biologics. Their use is indicated in moderate to severe disease in non responders to corti- costeroids and in steroid-dependent patients, as induc- tion and maintainance treatment. Infliximab, as well as cyclosporine, is considered a second line therapy in the case of severe ulcerative colitis, or non-responders to in- travenous corticosteroids. An adequate dosage and dura- tion of therapy with thiopurines should be reached before evaluating their efficacy. Methotrexate is a valid option in patients with Crohn’s disease but its use is confined to patients who are intolerant or non-responders to thiopu- rines. Evidence for the use of methotrexate in ulcerative colitis is insufficient. The use of thalidomide and myco- phenolate mofetil is not recommended in patients with inflammatory bowel disease, these treatments could be considered in case of failure of all other therapeutic op- tions. In patients with moderately active ulcerative colitis, refractory to thiopurines, the use of tacrolimus is consid- ered an alternative to biologics. An increase of the dose or a decrease in the interval of administration of biologi- cal treatment could be useful in the presence of an in- complete clinical response. In the case of primary failure
of an anti-tumor necrosis factor alpha a switch to another one should be considered. Data on the efficacy of com- bination therapy are up to now insufficient to consider this strategy in all IBD patients. The final outcome of the treatment should be considered the clinical remission, with mucosa healing, and not the clinical response. The evaluation of serum concentration of thiopurine methyl transferase activity, thiopurine metabolites, biologic se- rum levels and antibiologic antibodies could be useful for the management of the treatment but it has not been routinely applied in clinical practice. The evidence of high risk development of lymphoma and cutaneous malignan- cies should be considered in patients treated with immu- nosuppressants and biologics for a long period.
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Key words: Inflammatory bowel disease; Optimization; Immosuppressants; Biologics; Crohn’s disease; Ulcera- tive colitis
Core tip: The clinical expression of inflammatory bowel disease (IBD) is heterogeneous with different clinical courses, so it is not easy to find the best therapy for all patients. In recent years the goals of the therapy for IBD patients have evolved from symptomatic control to altering the course of disease by achieving a “deep remission”. Many trials have evaluated the efficacy of immunosuppressants and biologics in achieving clinical and endoscopic remission but the optimization of these treatments is still a debated point. We propose some recommendations about the correct use of immunosup- pressants and biologics for the treatment of IBD, based on the current evidence.
Renna S, Cottone M, Orlando A. Optimization of the treatment with immunosuppressants and biologics in inflammatory bowel disease. World J Gastroenterol 2014; 20(29): 9675-9690 Avail- able from: URL:
http://www.wjgnet.com/1007-9327/full/v20/ i29/9675.htm DOI:
http://dx.doi.org/10.3748/wjg.v20.i29.9675
