Biosimilars -Position Statement

Posted on October 26, 2015 by gutsandgrowth

Briefly noted:

“Use of Biosimilars in Paediatric Inflammatory Bowel Disease” Position Statement. JPGN 2015; 61: 503-08. Conclusions:

“IBD Porto group advocates giving high priority to performing paediatric trials with long-term followup to support” the use of biosimilars (97% agreement)
“Treatment of a child with sustained remission on a specific medication should not be switched to a biosimilar until clinical trials in IBD are available to support the safety and efficacy of such a change” (94% agreement)
“Postmarketing surveillance…in children with IBD should be a mandatory requirement.” (100% agreement)

My take: Keep this reference handy. The lower expected costs (>30% reduction) could create pressure to change treatment before the safety/efficacy is proven.

Atlanta Botanical Gardens

Should All Pediatric Patients with Crohn’s Disease Continue Combination Therapy?

Posted on October 22, 2015 by gutsandgrowth

Among patients/families who are not in denial about their inflammatory bowel disease, especially Crohn’s disease, an important discussion is the use of combination therapy. This has been discussed on this blog before (see some links below). More data on this subject has been published and again favors the use of combination therapy (V Grossi, T Lerer, et al. Clin Gastroenterol Hepatol 2015; 13: 1748-56).

This study collected data from 2002-2014 on 502 children who participated in a prospective multicenter study. This data was derived from an observational registry rather than a randomized trial, but likely reflects real-world experience with regard to newly diagnosed patients. The authors excluded those with prior biologic therapy and prior resectional surgery.

KEY FINDINGS:

Children receiving combination immunomodulator (IM) treatment were more likely to have durable infliximab therapy at 1 year, 3 years, and 5 years.
Greater length of concomitant IMs was associated with better durability.
For patients who had IM > 6 months after starting infliximab (n=194), durability was 0.70 at 5 years compared with 0.55 for patients with IM <6 months (n=144), and 0.48 for those who did not receive IMs (n=135).
In boys, methotrexate appeared to be superior to thiopurines (P<.01): 0.98 at 5 yrs compared with 0.58. However, there were 60 males receiving methotrexate. In the study, only 21 females received methotrexate which limited any conclusions.

Among patients who stopped IFX, the reasons included loss of response (n=61, 43%), hypersensitivity reaction (n=41, 29%), elective (n=25, 18%), lost to f/u (n=5, 3%), and other causes (10, 7%).

The “right” dose of methotrexate as a combination agent remains unclear. There was a wide range of dosing schedules in this study. It is worth observing that the COMMIT study in adults found no significant difference in adults who received methotrexate in addition to infliximab compared with those receiving infliximab monotherapy.

Take-home message: In this large pediatric observational study, the use of immunomodulators increased the likely durability of infliximab. Given prior conflicting data (particularly with regard to methotrexate), even more studies are needed to determine exactly how useful combination therapy is and when monotherapy will suffice. From my viewpoint, I worry much more about loss of efficacy to infliximab than I worry about medication adverse effects. As such, I will continue to inform families that combination therapy appears to improve infliximab durability.

Related blog posts:

Mount Washburn, Yellowstone

Anti-TNF Therapy: Rapid Reduction in Pain in Crohn’s Disease

Posted on October 19, 2015 by gutsandgrowth

A pretty cool use of technology provides strong evidence that decreased pain perception in the brain of patient’s with Crohn’s disease (CD) occurs well before anti-inflammatory effects like mucosal healing (A Hess et al. Gastroenterol 2015; 149: 864-66). In this study, the authors prospectively identified 4 patients with CD and performed functional MRI on day -1, day 1, and day 27. Key findings:

In three patients, who responded with a decrease in Harvey-Bradshaw Index by ≥2 points 14 weeks after anti-TNF initiation, the pain signal induced by either finger tapping or compression (see cover below) was markedly improved 1 day after anti-TNF initiation.
In the CD non responder, there was only slight reduction in signals at 24 hours and no improvement from baseline at day 27.

My take: This study explains why so many patients with severe symptoms can be managed quickly as outpatients. The effects of anti-TNF therapy on pain occur within 24 hrs! Pretty cool.

Final Tweets from #NASPGHAN15

Posted on October 18, 2015 by gutsandgrowth

From debate regarding importance of mucosal healing:

Related blog posts:

ER Evaluations of Visits Related to Inflammatory Bowel Disease

Posted on October 17, 2015 by gutsandgrowth

A short communication (C Pant et al. JPGN 2015; 61: 282-84, ed 267-8) provides some insight into what is happening in the ER when patient with inflammatory bowel disease are evaluated.

The authors analyzed a national database, the Healthcare Cost and Utilizationa Porject Nationwide Emergency Department Sample (NEDS), from 2006-2010.

Key findings:

ED visits for children 5-19 years of age increased from 14,527 (2006) –>18,193 (2010)
Frequency of computerized tomography (CT) imaging increased 80.43% (P<0.01) for Crohn’s disease and 59.26% (P<0.01) for ulcerative colitis
Overall rate of hospital admissions decreased by 14.32% (P<0.01)

The associated editorial by Jennifer Dotson and Michael Kappelman explain the limitations of relying on data that are derived mainly for billing rather than research and comment on the “alarming increase” in CT usage due to the risk of radiation exposure and the potential alternatives (eg. ultrasound, MRE). With regard to limitations, they likely included inaccurate and incomplete entries. In addition, the database included 950 hospitals, but may have under-sampled large freestanding children’s hospitals. This could skew the data. Finally, the data uses “visit-level” data rather than “patient-level” data; thus, one ‘cannot distinguish between a single patient who is seen on three separate visits or three unique patients.’

My take: There has been increasing use of ER visits and CT scanning for pediatric patients with IBD. One of my colleagues in town (Cary Sauer) has a humorous slide of a CT scanner as the entrance door to the ER. The message from this study indicates that we should be working on changing practice by working with our ER colleagues along with radiologists to minimize CT scans in favor of more gently imaging.

Related blog posts:

Atlanta Botanical Gardens, Bruce Munro exhibit

NY Times: “Should We Bank Our Own Stool?”

Posted on October 14, 2015 by gutsandgrowth

A provocative article poses the question: Should we bank our own stool?

Here’s an excerpt:

The scientific term for this is “autologous fecal transplant.” In theory, it could work like a system reboot disk works for your computer. You’d freeze your feces, which are roughly half microbes, and when your microbiome became corrupted or was depleted with antimicrobials, you could “reinstall” it from a backup copy.

That damage from antibiotics may not be trivial. Studies have linked antibiotic use early in life with a modestly increased risk of asthma,inflammatory bowel disease, obesity and rheumatoid arthritis. These are associations, of course; they don’t prove that antibiotics cause disease…

Almost 60 years later, the “fecal transplant” is a cutting-edge treatment for the pathogen Clostridium difficile, a bug that kills 29,000 yearly and infects nearly half a million…

Memorial Sloan Kettering Cancer Center in New York has also started a proactive stool-banking study. Most of the subjects are patients with leukemia. Before stem cell transplants, patients receive antibiotics andchemotherapy, often wiping out their microbiota…

OpenBiome…started a pilot self-banking program called “PersonalBiome.” One complication: If he stores your stool, you can generally withdraw it only to treat C. difficile, not for preventive “reconstitution.” That’s because stool is regulated as a drug and not, as with embryos or blood, a tissue, which makes its use more complex.

Related blog posts:

Atlanta Botanical Garden, Bruce Munro Exhibit

Targeted Therapy for PFIC type 2

Posted on October 12, 2015 by gutsandgrowth

Progressive Familial Intrahepatic Cholestasis, type 2, (PFIC2) is due to decrease (or absent) function of the bile salt export pump (BSEP) encoded by ABCB11 has been treated mainly in a symptomatic manner with medicines like ursodeoxycholic acid and sometimes biliary diversion. PFIC2 has been associated with increased risk for hepatocellular carcinoma (HCC).

A recent study (E Gonzales, et al. Hepatology 2015; 62: 558-66) indicates that newer therapies targeting the specific mutation may be effective.

In this study, treatment with oral 4-phenylbutyrate (4-PB) in four patients improved pruritus, serum bile acid concentrations, and liver function tests. 4-PB is considered a chaperone drug and may partially correct mistrafficking.

The associated editorial (pg 349-50) notes that 4-PB has an unpleasant taste and requires ingestion of a large number of pills. In addition, patients with complete loss of BSEP, 4-PB will not be effective. Finally, even in patients with a clinical response, it is unclear if this will lower the risk of HCC.

A second study (S Varma et al. Hepatology 2015; 62: 198-206) retrospectively studied 22 children with PFIC2. “Children with late-onset presentation, lower ALT, and intracellular BSEP expression are likely to respond, at least transiently, to nontransplant treatment.” Nontransplant treatment in this cohort included ursodeoxycholic acid in 19 (10 mg/kg thrice daily) and partial biliary diversion in 3. Higher ALT values were considered to be >165 IU/L. Another point in this study: response to treatment can be slow and take many months.

My take: These studies provide useful information about which patients with PFIC2 respond medically and introduce a new therapy, 4-PB.

Related blog posts:

Is this really newsworthy? Perhaps next week: man with venomous snakes says they make great pets?

Perhaps next week the story will be: man with venomous snakes says they make great pets?

Best Tweets Two #NASPGHAN15

Posted on October 10, 2015 by gutsandgrowth

One clarification -I do not think that Dr. Narkewicz is calling Dr. Balistreri a panda:

Best Tweets from Postgraduate Course: #NASPGHAN15

Posted on October 9, 2015 by gutsandgrowth

Since I am not at this year’s national meeting, I have followed some of the information on social media. Here are some of the best tweets:

Related blog posts:

Useful Information on Eosinophilic Disorders

Posted on September 30, 2015 by gutsandgrowth

A review (JB Wechsler et al. J Asthma Allergy 2014; 7: 85-94) provides practical advice on dietary management of eosinophilic esophagitis (EoE); the section on food reintroduction from elemental diets for patients with EoE is particularly helpful. They start with typically less allergenic foods (group A) to most allergenic (group D) -from their Table 2:

Group A:

Vegetables (nonlegume): carrots, squash, sweet potato, white potato, string beans, broccoli, lettuce, beets, asparagus, cauliflower, Brussel sprouts
Fruit (noncitrus, nontropical) apples, pear, peaches, plum, apricot, nectarine, grape, raisins
Vegetables: tomatoes, celery, cucumber, onion, garlic, and other vegetables

Group B

Citrus fruit: orange, grapefruit, lemon, lime
Tropical fruit: banana, kiwi, pineapple, mango, papaya, guava, avocado
Melons: honeydew, cantaloupe, watermelon
Berries: strawberry, blueberry, raspberry, cherry, cranberry

Group C

Legumes: lima beans, chickpeas, white/black/red beans
Grains: oat, barley, rye, other grains
Meat: lamb, chicken, turkey, pork

Group D

Fish/shellfish
Corn
Peas
Peanut
Wheat
Beef
Soy
Egg
Milk

Also, this review includes a long list of “freebie” foods allowed while on elemental diet, including artificial flavors/colors, corn syrup, oils, salt, crystal lite, and many others.

The authors note that “in our practice, the period of exclusive elemental formula is limited to 4 weeks prior to therapeutic assessment by endoscopy and reintroduction…Single foods are introduced every 5-7 days” within a group and then endoscopy after 3-4 foods are clinically tolerated.” Foods from groups C and D are introduced more cautiously.

Also noted: HM Ko et al. Am J Gastroenterol 2014; 109: 1277-85. This retrospective study of 30 children with severe gastric eosinophilia (mean age 7.5 years) provides a good deal of useful information. Key point: “the disease is highly responsive to dietary restriction therapies.” 82% of patients responded to dietary restrictions and 78% had a histologic response as well. Dietary treatments included amino acid-based diet in 6 (n=6), 7-food group empiric diet (n=6), and empiric avoidance of 1-3 foods (n=5). Pharmacologic treatments (proton pump inhibitor or cromolyn) were attempted in a total of four patients in this series with half responding clinically and one of four responding histologically.

Related blog posts:

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

gutsandgrowth

Pediatric Gastroenterology

Category Archives: Pediatric Gastroenterology Intestinal Disorder

Biosimilars -Position Statement

Should All Pediatric Patients with Crohn’s Disease Continue Combination Therapy?

Anti-TNF Therapy: Rapid Reduction in Pain in Crohn’s Disease

Final Tweets from #NASPGHAN15

ER Evaluations of Visits Related to Inflammatory Bowel Disease

NY Times: “Should We Bank Our Own Stool?”

Targeted Therapy for PFIC type 2

Best Tweets Two #NASPGHAN15

Best Tweets from Postgraduate Course: #NASPGHAN15

Useful Information on Eosinophilic Disorders