Recycled Precolectomy Anti-Tumor Necrosis Factor Does Not Work for Chronic Pouchitis
Monika Fischer, MD, reviewing Kayal M, et al. Clin Gastroenterol Hepatol 2020 Jul 11.
Following total proctocolectomy with restorative ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC), about one-third of patients develop chronic pouchitis. Treatment of antibiotic-refractory and Crohn’s disease-like pouchitis is challenging. A majority of these patients fail at least one or more anti-tumor necrosis factor (TNF) drug or biologic drug from another class before their colectomy. It is unclear whether reinitiating an anti-TNF drug in this case scenario would be beneficial.
In this retrospective single-center study, 83 adult patients with IPAA who were taking a biologic drug for chronic antibiotic-refractory and/or steroid-refractory pouchitis were evaluated and followed for a mean of 3 years. Among these patients, 53% used an anti-TNF for UC before colectomy, and all of them lost response to the therapy despite a therapeutic drug concentration and a lack of antibodies. Most patients used infliximab (81.8%), while a few received adalimumab (15.9%) or golimumab (2.23%). Over half also used an immunomodulator.
For the chronic pouchitis, adalimumab was given to 43 (51.8%) patients, infliximab to 24 (28.9%), vedolizumab to 7 (8.4%), ustekinumab to 6 (7.2%), and certolizumab to 3 (3.6%). Patients who were treated with anti-TNF therapy precolectomy and postcolectomy were less likely to achieve clinical remission (adjusted odds ratio, 0.20; 95% confidence interval [CI], 0.06-0.61) and more likely to lose their pouch (odds ratio, 4.9; 95% CI, 1.34-18.13) compared to those who were biologic-naïve preoperatively or exposed to a different biologic class postoperatively.
COMMENTThis study suggests that patients who fail anti-TNF therapy despite optimal drug concentration and no detectable antibodies (had a so-called mechanistic failure to an anti-TNF) prior to colectomy are unlikely to respond to any anti-TNF drugs for the treatment of antibiotic-refractory chronic pouchitis or Crohn’s disease-like pouchitis. Therefore, it is prudent to recommend a biologic drug, such as ustekinumab or vedolizumab, from a different class.
Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.
CITATION(S)
Kayal M, Lambin T, Plietz M, et al. Recycling of pre-colectomy anti-tumor necrosis factor agents in chronic pouch inflammation is associated with treatment failure. Clin Gastroenterol Hepatol 2020 Jul 11. (Epub ahead of print) (https://doi.org/10.1016/j.cgh.2020.07.008)
