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Fecal Lactoferrin as Biomarker for Monitoring the Mucosal Status in Patients With Ulcerative Colitis and Irritable Bowel Syndome
Figure 1: Dose-dependent anti-TNF-α neutralizing effect of infliximab, infliximab F(ab)2, adalimumab, certolizumab, etanercept and golimumab. Sa1303 Sa1305 Limited Clinical Utility of a Self-Administered Tool for Predicting Medication Adherence Behavior in IBD Sunanda V. Kane, Edward V. Loftus, William J. Sandborn, Darrell S. Pardi, David H. Bruining, Kenneth W. Schroeder, Brenda D. Becker, William A. Faubion, Karen A. Hanson, Alan R. Zinsmeister, William S. Harmsen
Clinical Value of Measuring Trough Levels and Human Anti-Chimeric Antibodies in Patients With Inflammatory Bowel Disease Who Lost Response to Infliximab Therapy Benjamin Pariente, Guillaume Pineton de Chambrun, Marine Desroches, Chiara De Cassan, Jean-Marc Gornet, Pierre Desreumaux, Roman Krzysiek, Dominique Emilie, JeanFrederic Colombel, Matthieu Allez
Background and Aims: Identification of non-adherence is an important component of shortand long-term management of IBD. A validated screening tool for non-adherence in IBD would help determine those patients who may be at highest risk for non-adherent behavior and potentially worse disease outcomes. Our aim was to determine if scores from a selfreported adherence survey of IBD patients correlated with pharmacy refill data, as a reliable measure of medication adherence. Methods: The self-reported tool was an 8-item survey, the Moritsky Medication Adherence Scale, which has been previously validated in patients with hypertension. Each question is worth a point with a maximum score of 8. A score of <4 was defined as a patient at high risk for non-adherence, and a score of 7-8 at no risk for non-adherence. The study was IRB-approved and informed consent was obtained. Surveys were completed at the time of a routine clinic appointment. Patient pharmacies were contacted at 3 time points: time of enrollment for refill information regarding the previous 3 months, then 3 months and 6 months from enrollment. Medications discontinued due to intolerance or non-response before the 6-month time period were excluded. Refill data were recorded for each time interval as the Medication Possession Ratio (MPR) and adherence was defined as greater than 80%. Analysis of variance with Pearson's correlation coefficient was used to determine the relationship between survey scores and MPR by drug class. Results: One hundred fifty consecutive patients were enrolled. Ninety-four patients had Crohn's disease and 56 had ulcerative colitis. Eighty-nine patients (59%) were female. Thirty six percent of patients were on a 5-ASA, 41% on a thiopurine, 11% on infliximab, 6% on an injectable biologic, and 5% on budesonide. The median adherence score was 7 (range, 0-8). Fiftytwo percent stated they rarely missed a dose of medication. However, the adherence by refill data ranged from 25% to 71% by drug class. Only those on a thiopurine had a survey score that positively correlated with adherence (p = 0.02). For all other medication classes, there was no correlation between reported scores and refill data either prior to or 6 months following survey completion. Conclusion: Overall, adherence with IBD therapies was low. Only those on a thiopurine were likely to have an adherence score that predicted high refill behavior. Adherence with therapy for IBD is complex and cannot be predicted in a reliable manner by a self-reported survey tool validated for other chronic conditions.
Introduction: Infliximab (IFX) has been shown to be effective for the treatment of refractory inflammatory bowel disease (IBD). Despite a good initial response to IFX, up to 40 % of patients will lose response over time. The clinical management of IBD patients with loss of response to IFX remains empiric. Aim: To study the clinical value of measuring IFX trough level and human anti-chimeric antibodies (HACA) concentrations in IBD patients who lost response to IFX therapy. Patients and methods: In a retrospective study, IBD patients with loss of response to IFX therapy and who underwent HACA and IFX concentration testing between 2008 and 2010 in two French tertiary referral centers, were included. Physicians managing patients who lost response to IFX therapy were not aware of results of IFX and HACA concentration testing. Results: Eighty two IBD patients who lost response to IFX therapy were included. Thirty-six patients (44%) continued IFX therapy without any modification, 40 patients (49%) had an intensification of IFX therapy (defined as an increase in IFX dose or as a decrease in the frequency of infusion), 5 patients (6%) had a change to adalimumab therapy, and one patient (1%) underwent surgery. Clinical response was observed in 70% of patients with an intensification of IFX therapy and 80% of patients with a change to adalimumab as compared with 31% of patients without modification of IFX therapy (p<0.04). In patients with an intensification of IFX therapy, IFX trough level was similar between patients with or without clinical response (3.2±3.9 and 2.3±2.19mcg/mL respectively, p>0.3). We divided patients with an intensification of IFX therapy in quartiles regarding IFX trough level (<0.2, 0.2-1.55, 1.55-4.32 and >4.32mcg/mL). Rates of clinical response were similar in the 4 groups (67%, 73%, 70% and 70% respectively, p>0.8). Of the 82 patients with loss of response to IFX, 18 (22%) presented detectable HACA in the serum. Positive HACA status was significantly associated with a low IFX trough level (p<0.001). Ten HACA positive patients had an intensification of IFX therapy and 6 of these patients (60%) presented a clinical response. Seven patients with positive HACA and an intensification of IFX therapy had a second testing for HACA during the follow-up. Five of these patients (71%) presented either a decreased or a negativity of their HACA titers. Conclusion: In patients with IBD in loss of response to IFX, clinical response to intensification of IFX therapy is not related to IFX serum concentration. Intensification of IFX could be effective in patients with detectable HACA in the serum.
Sa1304 Quantitative Comparison of the Neutralizing Capacity of Therapeutic AntiTNF-α Drugs and the Cross-Reactivity of Anti-Anti-TNF-α Antibodies Dorien J. Buurman, B. T. Pham, Tjasso Blokzijl, Klaas Nico Faber, Elise M. van der Logt, Suzanne Arends, Elisabeth Brouwer, Maikel P. Peppelenbosch, Jan H. Kleibeuker, Gerard Dijkstra
Sa1306 Fecal Lactoferrin as Biomarker for Monitoring the Mucosal Status in Patients With Ulcerative Colitis and Irritable Bowel Syndome Jost Langhorst, Miriam Mohr, Andreas Rueffer, Gustav J. Dobos, James H. Boone
Introduction: TNF-α blocking drugs, such as infliximab (IFX) and adalimumab (ADA), are highly effective in the treatment of Crohn's disease (CD) and rheumatoid arthritis (RA). There is no head to head comparison between these drugs. Furthermore many patients develop antibodies against these drugs, even when cotreated with immunosuppressives, which leads to loss of response and/or adverse infusion reactions. It is unclear whether the anti-anti-TNF-α antibodies neutralize the anti-TNF-α drug and whether they show crossreactivity towards other available anti-TNF-α therapeutics. Here, we compared the TNF-αneutralizing capacity of all available anti-TNF-α drugs, as well as the antigenic cross-reactivity of anti-anti-TNF-α antibodies. Methods: We developed a sensitive and quantitative TNF-α sensor assay using HeLa 8D8 cells that express the Green Fluorescence Protein (GFP) under control of an NF-κB response element. GFP expression was quantified by flow cytometry. All commercially available anti-TNF-α drugs and the F(ab)2 fragment of infliximab (IFXFab) (dose range 0-40 ng/ml) were tested for their TNF-α-neutralizing capacity. In addition, patient sera with specific anti-anti-TNF-α antibodies were tested for their potential to block the activity of anti-TNF-α drugs. Results: TNF-α (1 ng) strongly induced GFP expression in Hela 8D8 cells. Higher concentrations of the first generation anti-TNF-α drugs IFX and ADA were required to neutralize TNF-α compared to etanercept (ETA), certolizumab and golimumab. Serum of 11 CD patients and 10 arthritis patients with established anti-IFX
INTRODUCTION: For several decades clinical disease activity was the main treatment goal in ulcerative colitis (UC). However, recently mucosal healing is discussed to be a mayor goal for therapy. Furthermore, mucosal status is crucial to discriminate UC from irritable bowel syndrome (IBS) which may present with similar symptoms. Reliable markers are needed to properly monitor mucosal status on a histological level. Fecal Lactoferrin (FLA), a neutrophil-derived protein, has been shown to be a useful biomarker to discriminate IBS from UC and measuring intestinal inflammation in UC. AIMS: To investigate FLA, CRP and the colitis activity index (CAI) defined by Rachmilewitz to monitor status of inflammation on a mucosal level using six histological features in patients with UC and IBS. Methods: We performed 281 endoscopic procedures in 242 pts (male:female 1:1.5, age range 15-75 yrs) including 175 with UC and 67 with IBS. Fecal specimens were collected and analyzed for FLA (≥ 7 g/mg for elevated), using enzyme-linked immunoassay and serum for CRP (> 0.5 mg/dl for elevated). The CAI (> 4 indicating acute disease) was calculated for both UC and IBS. Every patient underwent endoscopy. Three sigmoidal biopsies and three rectal biopsies were taken in each procedure for histopathological work up. All specimens were investigated for chronic inflammatory cell infiltrate and architectural irregularities. Furthermore, signs of acute inflammation such as acute inflammatory cell infiltrate, crypt abscesses,
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and anti-ADA antibody titers blocked the TNF-α-neutralizing properties of IFX and ADA, respectively, but did not show cross-reactivity. Serum of 2 patients with loss of response or non response to ETA did not show a blocking effect on TNF-α neutralizing properties of ETA, suggesting that the loss of response in these patients was not related to the formation of anti-ETA antibodies. Conclusion: The second generation anti-TNF-α drugs show increased TNF-α neutralizing potential. Anti-IFX and anti-ADA antibodies do not show antigenic cross-reactivity. Patients with loss of response due to anti-anti-TNF-α antibody formation may still respond to other anti-TNF-α drugs.
AGA Abstracts
mucin depletion and breaches in the surface epithelium were evaluated and included in an acute inflammation index. All six categories were included in a histological sum score. RESULTS: Of the 281 histological work ups 121 showed an acute inflammation index ≥ 1 indicating acute inflammation on a mucosal level. FLA showed a median ± STD of 2.3 ± 19.4 μg/mg for no inflammation and 37.9 ± 211.4 μg/mg for active inflammation. Mean FLA, CRP and CAI discriminated pts with acute inflammation from those with no signs of inflammation high significantly (p < 0.0001). Sensitivity and specificity in FLA was 78% and 69%, 39% and 82% in CRP and 44% and 88% in CAI, respectively. Diagnostic accuracy was 72.6% for FLA, 64% for CRP and 69.7% for the CAI. FLA showed highest correlation to the acute inflammation index (FLA cc =.476; p <.000; CRP cc =.214; p <.000; CAI cc = .445 p <.000) as well as the histological sum score (Spearman correlation coefficient FLA cc =.543; p <.000; CRP cc =.230; p <.000; CAI cc =.244 p <.000). CONCLUSION: Our data confirm the poor correlation of CRP to mucosal status defined by an acute inflammation index as well as a histological sum score. Fecal lactoferrin does serve as a useful biomarker for monitoring the mucosal status in patients with IBS and gives crucial information about status of mucosal healing in ulcerative colitis.
Sa1309 Oxidative DNA Damage Levels in IBD Patients Undergoing Infliximab Therapy Sudarshan Paramsothy, Payal Saxena, Ramesh Paramsothy, Irina E. Piatkov, Rupert W. Leong BACKGROUND AND AIMS: Infliximab (IFX) induces T cell apoptosis and lymphocyteDNA is released into the blood and oxidized. Measuring pre- and post-IFX oxidized DNA may help identify those in whom IFX is efficacious and predict those with primary or secondary non-response. This pilot study quantifies oxidative DNA damage in blood and urine pre- and post- IFX and correlates this with disease severity and treatment response. METHODS: Consecutive IBD patients receiving IFX were recruited. Quantitative oxidative DNA damage was measured pre- and post- IFX infusion with urine 8- hydroxy-2-deoxyguanosine (8-HDOG, in ng/mg Cr) levels and serum aldehyde reactive probe (ARP) number which measures abasic (apurinic/apyrimidinic) sites per 105 base pairs in genomic DNA. Disease activity markers (albumin, CRP, ESR, Hb, WCC, platelets), Montreal phenotype of location (perianal, colon, ileum, UGIT) and other IBD medication use (steroids, azathioprine/6-MP, methotrexate, 5-ASA) were recorded. Mann Whitney U, Pearson and Spearman correlation statistical tests were performed. RESULTS: Thirteen infusions on 12 patients (7 females, 5 males) were analysed (missing data for 3 urine and 4 serum samples). Urine 8-HDOG values pre-IFX median was 1.91 (range 1.16-6.28) and post-IFX median was 3.51 (range 0.5810.53, difference P =0.065). Serum ARP numbers pre-IFX median was 9.30 (range 4.722.8) and post-IFX median was 9.4 (range 0.8-33.8, difference P=0.595). There was no correlation between serum difference and urine difference pre- and post- IFX (R= 0.546 ,P= 0.205). CRP was inversely correlated with urine difference (r= -0.645, P=0.032) with a trend towards inverse correlation with serum difference (r= -0.611, P=0.081). Pre- and post-IFX serum or urine levels were not associated with other biochemical parameters, CDAI, disease location phenotype or use of other IBD medications. CONCLUSIONS: In this pilot study, urinary 8-HDOG levels increased after IFX infusion, hypothesized to be due to DNA release and oxidative damage. Inverse correlation of 8-HDOG with CRP levels may represent evidence of therapeutic efficacy. Urine 8-HDOG may be a biomolecular marker of IFX efficacy. Further confirmatory studies are planned. Table of Main Results
Sa1307 Infliximab Modifies Circulating Reactive Oxygen Species and Restores Serum Antioxidant Potential in Inflammatory Bowel Disease Patients Luca Pastorelli, Cristian Testa, Carlo De Salvo, Luisa Spina, Gianeugenio Tontini, Nadia Munizio, Maurizio Vecchi Aim of the study: Circulating reactive oxygen species (ROS) are significantly increased during inflammatory states. ROS production can cause direct tissue damage, altering biomolecules, such as lipids, proteins and nucleic acids, and increase inflammatory responses upon activation of pro-inflammatory pathways. ROS production has been reported to play a role in eliciting the inflammatory cascade and mucosal injury characterizing Inflammatory Bowel Diseases (IBD); in fact IBD patients display elevated serum and tissue ROS and reduced levels of antioxidant enzymes, and free radical scavenger compounds have been shown to be effective in ameliorating intestinal inflammation in experimental models of colitis. Accordingly, TNFα, a key inflammatory mediator in IBD, increases ROS production. AntiTNFα monoclonal antibody therapy is indeed effective in inducing remission or reducing disease activity in IBD; however, the blockade of TNFα acts at different levels, which are yet to be fully characterized. Aim of the present study is to evaluate if anti-TNFα therapy may modify oxidoreductive state in IBD patients. Materials and methods: 42 sera were collected from 14 IBD patients (8 CD, 6 UC), before each of the first 3 Infliximab (IFX) infusions of the therapeutic induction regimen. Serum ROS were evaluated using the dROM test, spectrophotometric test based on the measurement of hydroperoxide generated by ROS; biological antioxidant potential (BAP), as a measure of plasmatic antioxidant barrier, was determined using the BAP test, colorimetric test assessing the plasmatic antioxidant power. Statistical analysis was performed by means of paired Student's t test. Results: Serum ROS levels were markedly reduced throughout IFX therapy, as observed comparing the first to the third infusion (370.49±135.58 vs. 294.46±96.94 Ucarr; p<0.005); BAP was transiently increased after the first infusion (4251.63±508.36 vs. 4950.93±460.35 mmol/l; p<0.0005), but was restored to the original level before the third infusion. Conclusions: Taken together, our data show that anti-TNFα therapy significantly modifies serum oxidative stress in IBD patients, reducing ROS production and increasing antioxidant potential, suggesting another possible mechanism through which IFX exerts its therapeutic effect.
Sa1310 Therapeutic Decision Making in Newly Diagnosed Crohn's Disease Patients Veerle J. Nuij, Judith E. Baars, Ernst J. Kuipers, Christien J. van der Woude Background and aims: Guidelines based on literature recommend a step-up approach for the induction and maintenance of remission in Crohn's disease (CD). However the same guidelines lack directions for timing these step-up decisions. Furthermore, a top-down approach is increasingly advocated under the assumption that this may prevent long-term complications. Given this discrepancy, we were interested in therapeutic decision making in current clinical practice in newly diagnosed CD patients (pts). Furthermore, we wanted to know whether the disease phenotype at diagnosis influences the number of step-up decisions during follow-up. Methods: In four general hospitals in the South-West of The Netherlands all newly diagnosed CD pts between January 1st, 2006 and January 1st, 2007 were included. End of follow-up was January 1st, 2010. Data on patient-, and disease characteristics were derived from the medical records. Therapeutic decisions after start of initial therapy were scored as follows: no change, step-down, change within therapeutic group, and step-up. Statistical analysis was performed using Chi-square tests and Cramer's V. Results: In total, 102 pts were diagnosed with CD, of whom 100 (98%) could be included (one patient died, one moved abroad). Forty-five pts (45%) were male. Median follow-up time was 40.7 months (IQR 37.5 - 43.8). In total, 227 therapeutic step-up decisions were made in 81 (81%) pts, and 19 (19%) pts underwent 24 surgical procedures. Three (3%) pts were referred to a tertiary IBD clinic. Sixty-six (66%) patients used 5-ASA as a part of initial therapy. Of the 252 therapeutic step-up decisions, 86 (34%) included start of corticosteroids, 67 (26.6%) included step-up to immunosuppressants and 46 (18.3%) included step-up to anti-TNF. The median number of step-ups per patient was 2 (range 012). Reasons for step-up decisions were mainly based on symptoms (38%) and not on endoscopy (only 13%). Pts visiting the outpatient clinic more frequently had significantly more step-ups (p < 0,001, correlation 0.729). Pts with extra-intestinal manifestations, fistulas, or perianal disease with fistulas or abscesses had a similar number of step-ups compared with pts without these manifestations. The number of visits to the outpatient clinic did not differ between these groups. Conclusions: Despite current guidelines, 5-ASA is still prescribed in the majority of newly diagnosed CD pts. However 51% of the newly diagnosed CD pts require a step-up therapy within three months after diagnosis often based on non-invasive parameters only. The most prescribed therapy for CD are corticosteroids. Overall, a large proportion of newly diagnosed patients undergo frequent medical changes. These results state that the current policy needs to be optimized. However, as we have no data on disease outcome yet, we need to be careful with this statement.
Sa1308 Anti-TNF Therapy Improves Stored Body Iron Serum Markers in Inflammatory Bowel Disease Patients Luca Pastorelli, Cristian Testa, Roberta Rigolini, Paola Giubbilini, Luisa Spina, Gianeugenio Tontini, Nadia Munizio, Carlo De Salvo, Benedetta Rampoldi, Elena Costa, Maurizio Vecchi Aim of the study: Chronic intestinal inflammation, characterizing Inflammatory Bowel Diseases (IBD), may cause profound changes in gut tissue architecture, resulting eventually in nutrient malabsorption and chronic loss of blood from gut mucosa. Moreover, the chronic inflammatory state is able to induce the activation of the reticuloendothelial system, and consequent iron sequestration. Thus, IBD patients often present iron deficiency and alterations of iron markers leading to anemia or other clinical conditions. Infliximab (IFX) is a chimeric anti-TNFα monoclonal antibody, currently used as a therapeutic option in moderate to severe IBD. Indeed effective in inducing remission or reducing disease activity, the blockade of TNFα acts at different levels, which are yet to be fully characterized. Aim of the present study is to evaluate if IFX therapy exerts direct effects of on stored body iron in IBD patients. Materials and methods: 42 sera were collected from 14 IBD patients (8 CD, 6 UC), before each IFX infusion, for the first 3 infusions of the therapeutic regimen. Serum ferritin was determined by a solid-phase two-site chemiluminescent immunometric assay, instead transferrin and CRP levels were measured by a immunoturbidimetric and iron by a colorimetric assay. Statistical analysis was performed by means of paired Student's t test. Results: Serum iron significantly increased between the first and the third IFX infusion (36.71±11.98 vs. 48.14±19.51 μg/dl, p<0.05), as well as serum total transferrin (202.57±43.11 vs. 252.29±39.90 mg/dl, p<0.01); CRP was significantly reduced (2.06±2.26 vs. 0.49±0.52 mg/ dl, p<0.05), while a trend towards ferritin decrease was detectable, although not significant (64.14±71.50 vs. 27.50±30.80 ng/ml, p=0.06). Conclusions: Taken together, our data show that anti-TNFα therapy significantly modifies serum markers of stored body iron, suggesting that, inducing mucosal healing, IFX may restore iron absorption and reduce intestinal iron loss, but also it may directly modulate the cytokine network regulating iron metabolism in the reticuloendothelial system.
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Clinical Value of Measuring Trough Levels and Human Anti-Chimeric Antibodies in Patients With Inflammatory Bowel Disease Who Lost Response to Infliximab Therapy Benjamin Pariente, Guillaume Pineton de Chambrun, Marine Desroches, Chiara De Cassan, Jean-Marc Gornet, Pierre Desreumaux, Roman Krzysiek, Dominique Emilie, JeanFrederic Colombel, Matthieu Allez
Background and Aims: Identification of non-adherence is an important component of shortand long-term management of IBD. A validated screening tool for non-adherence in IBD would help determine those patients who may be at highest risk for non-adherent behavior and potentially worse disease outcomes. Our aim was to determine if scores from a selfreported adherence survey of IBD patients correlated with pharmacy refill data, as a reliable measure of medication adherence. Methods: The self-reported tool was an 8-item survey, the Moritsky Medication Adherence Scale, which has been previously validated in patients with hypertension. Each question is worth a point with a maximum score of 8. A score of <4 was defined as a patient at high risk for non-adherence, and a score of 7-8 at no risk for non-adherence. The study was IRB-approved and informed consent was obtained. Surveys were completed at the time of a routine clinic appointment. Patient pharmacies were contacted at 3 time points: time of enrollment for refill information regarding the previous 3 months, then 3 months and 6 months from enrollment. Medications discontinued due to intolerance or non-response before the 6-month time period were excluded. Refill data were recorded for each time interval as the Medication Possession Ratio (MPR) and adherence was defined as greater than 80%. Analysis of variance with Pearson's correlation coefficient was used to determine the relationship between survey scores and MPR by drug class. Results: One hundred fifty consecutive patients were enrolled. Ninety-four patients had Crohn's disease and 56 had ulcerative colitis. Eighty-nine patients (59%) were female. Thirty six percent of patients were on a 5-ASA, 41% on a thiopurine, 11% on infliximab, 6% on an injectable biologic, and 5% on budesonide. The median adherence score was 7 (range, 0-8). Fiftytwo percent stated they rarely missed a dose of medication. However, the adherence by refill data ranged from 25% to 71% by drug class. Only those on a thiopurine had a survey score that positively correlated with adherence (p = 0.02). For all other medication classes, there was no correlation between reported scores and refill data either prior to or 6 months following survey completion. Conclusion: Overall, adherence with IBD therapies was low. Only those on a thiopurine were likely to have an adherence score that predicted high refill behavior. Adherence with therapy for IBD is complex and cannot be predicted in a reliable manner by a self-reported survey tool validated for other chronic conditions.
Introduction: Infliximab (IFX) has been shown to be effective for the treatment of refractory inflammatory bowel disease (IBD). Despite a good initial response to IFX, up to 40 % of patients will lose response over time. The clinical management of IBD patients with loss of response to IFX remains empiric. Aim: To study the clinical value of measuring IFX trough level and human anti-chimeric antibodies (HACA) concentrations in IBD patients who lost response to IFX therapy. Patients and methods: In a retrospective study, IBD patients with loss of response to IFX therapy and who underwent HACA and IFX concentration testing between 2008 and 2010 in two French tertiary referral centers, were included. Physicians managing patients who lost response to IFX therapy were not aware of results of IFX and HACA concentration testing. Results: Eighty two IBD patients who lost response to IFX therapy were included. Thirty-six patients (44%) continued IFX therapy without any modification, 40 patients (49%) had an intensification of IFX therapy (defined as an increase in IFX dose or as a decrease in the frequency of infusion), 5 patients (6%) had a change to adalimumab therapy, and one patient (1%) underwent surgery. Clinical response was observed in 70% of patients with an intensification of IFX therapy and 80% of patients with a change to adalimumab as compared with 31% of patients without modification of IFX therapy (p<0.04). In patients with an intensification of IFX therapy, IFX trough level was similar between patients with or without clinical response (3.2±3.9 and 2.3±2.19mcg/mL respectively, p>0.3). We divided patients with an intensification of IFX therapy in quartiles regarding IFX trough level (<0.2, 0.2-1.55, 1.55-4.32 and >4.32mcg/mL). Rates of clinical response were similar in the 4 groups (67%, 73%, 70% and 70% respectively, p>0.8). Of the 82 patients with loss of response to IFX, 18 (22%) presented detectable HACA in the serum. Positive HACA status was significantly associated with a low IFX trough level (p<0.001). Ten HACA positive patients had an intensification of IFX therapy and 6 of these patients (60%) presented a clinical response. Seven patients with positive HACA and an intensification of IFX therapy had a second testing for HACA during the follow-up. Five of these patients (71%) presented either a decreased or a negativity of their HACA titers. Conclusion: In patients with IBD in loss of response to IFX, clinical response to intensification of IFX therapy is not related to IFX serum concentration. Intensification of IFX could be effective in patients with detectable HACA in the serum.
Sa1304 Quantitative Comparison of the Neutralizing Capacity of Therapeutic AntiTNF-α Drugs and the Cross-Reactivity of Anti-Anti-TNF-α Antibodies Dorien J. Buurman, B. T. Pham, Tjasso Blokzijl, Klaas Nico Faber, Elise M. van der Logt, Suzanne Arends, Elisabeth Brouwer, Maikel P. Peppelenbosch, Jan H. Kleibeuker, Gerard Dijkstra
Sa1306 Fecal Lactoferrin as Biomarker for Monitoring the Mucosal Status in Patients With Ulcerative Colitis and Irritable Bowel Syndome Jost Langhorst, Miriam Mohr, Andreas Rueffer, Gustav J. Dobos, James H. Boone
Introduction: TNF-α blocking drugs, such as infliximab (IFX) and adalimumab (ADA), are highly effective in the treatment of Crohn's disease (CD) and rheumatoid arthritis (RA). There is no head to head comparison between these drugs. Furthermore many patients develop antibodies against these drugs, even when cotreated with immunosuppressives, which leads to loss of response and/or adverse infusion reactions. It is unclear whether the anti-anti-TNF-α antibodies neutralize the anti-TNF-α drug and whether they show crossreactivity towards other available anti-TNF-α therapeutics. Here, we compared the TNF-αneutralizing capacity of all available anti-TNF-α drugs, as well as the antigenic cross-reactivity of anti-anti-TNF-α antibodies. Methods: We developed a sensitive and quantitative TNF-α sensor assay using HeLa 8D8 cells that express the Green Fluorescence Protein (GFP) under control of an NF-κB response element. GFP expression was quantified by flow cytometry. All commercially available anti-TNF-α drugs and the F(ab)2 fragment of infliximab (IFXFab) (dose range 0-40 ng/ml) were tested for their TNF-α-neutralizing capacity. In addition, patient sera with specific anti-anti-TNF-α antibodies were tested for their potential to block the activity of anti-TNF-α drugs. Results: TNF-α (1 ng) strongly induced GFP expression in Hela 8D8 cells. Higher concentrations of the first generation anti-TNF-α drugs IFX and ADA were required to neutralize TNF-α compared to etanercept (ETA), certolizumab and golimumab. Serum of 11 CD patients and 10 arthritis patients with established anti-IFX
INTRODUCTION: For several decades clinical disease activity was the main treatment goal in ulcerative colitis (UC). However, recently mucosal healing is discussed to be a mayor goal for therapy. Furthermore, mucosal status is crucial to discriminate UC from irritable bowel syndrome (IBS) which may present with similar symptoms. Reliable markers are needed to properly monitor mucosal status on a histological level. Fecal Lactoferrin (FLA), a neutrophil-derived protein, has been shown to be a useful biomarker to discriminate IBS from UC and measuring intestinal inflammation in UC. AIMS: To investigate FLA, CRP and the colitis activity index (CAI) defined by Rachmilewitz to monitor status of inflammation on a mucosal level using six histological features in patients with UC and IBS. Methods: We performed 281 endoscopic procedures in 242 pts (male:female 1:1.5, age range 15-75 yrs) including 175 with UC and 67 with IBS. Fecal specimens were collected and analyzed for FLA (≥ 7 g/mg for elevated), using enzyme-linked immunoassay and serum for CRP (> 0.5 mg/dl for elevated). The CAI (> 4 indicating acute disease) was calculated for both UC and IBS. Every patient underwent endoscopy. Three sigmoidal biopsies and three rectal biopsies were taken in each procedure for histopathological work up. All specimens were investigated for chronic inflammatory cell infiltrate and architectural irregularities. Furthermore, signs of acute inflammation such as acute inflammatory cell infiltrate, crypt abscesses,
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and anti-ADA antibody titers blocked the TNF-α-neutralizing properties of IFX and ADA, respectively, but did not show cross-reactivity. Serum of 2 patients with loss of response or non response to ETA did not show a blocking effect on TNF-α neutralizing properties of ETA, suggesting that the loss of response in these patients was not related to the formation of anti-ETA antibodies. Conclusion: The second generation anti-TNF-α drugs show increased TNF-α neutralizing potential. Anti-IFX and anti-ADA antibodies do not show antigenic cross-reactivity. Patients with loss of response due to anti-anti-TNF-α antibody formation may still respond to other anti-TNF-α drugs.
AGA Abstracts
mucin depletion and breaches in the surface epithelium were evaluated and included in an acute inflammation index. All six categories were included in a histological sum score. RESULTS: Of the 281 histological work ups 121 showed an acute inflammation index ≥ 1 indicating acute inflammation on a mucosal level. FLA showed a median ± STD of 2.3 ± 19.4 μg/mg for no inflammation and 37.9 ± 211.4 μg/mg for active inflammation. Mean FLA, CRP and CAI discriminated pts with acute inflammation from those with no signs of inflammation high significantly (p < 0.0001). Sensitivity and specificity in FLA was 78% and 69%, 39% and 82% in CRP and 44% and 88% in CAI, respectively. Diagnostic accuracy was 72.6% for FLA, 64% for CRP and 69.7% for the CAI. FLA showed highest correlation to the acute inflammation index (FLA cc =.476; p <.000; CRP cc =.214; p <.000; CAI cc = .445 p <.000) as well as the histological sum score (Spearman correlation coefficient FLA cc =.543; p <.000; CRP cc =.230; p <.000; CAI cc =.244 p <.000). CONCLUSION: Our data confirm the poor correlation of CRP to mucosal status defined by an acute inflammation index as well as a histological sum score. Fecal lactoferrin does serve as a useful biomarker for monitoring the mucosal status in patients with IBS and gives crucial information about status of mucosal healing in ulcerative colitis.
Sa1309 Oxidative DNA Damage Levels in IBD Patients Undergoing Infliximab Therapy Sudarshan Paramsothy, Payal Saxena, Ramesh Paramsothy, Irina E. Piatkov, Rupert W. Leong BACKGROUND AND AIMS: Infliximab (IFX) induces T cell apoptosis and lymphocyteDNA is released into the blood and oxidized. Measuring pre- and post-IFX oxidized DNA may help identify those in whom IFX is efficacious and predict those with primary or secondary non-response. This pilot study quantifies oxidative DNA damage in blood and urine pre- and post- IFX and correlates this with disease severity and treatment response. METHODS: Consecutive IBD patients receiving IFX were recruited. Quantitative oxidative DNA damage was measured pre- and post- IFX infusion with urine 8- hydroxy-2-deoxyguanosine (8-HDOG, in ng/mg Cr) levels and serum aldehyde reactive probe (ARP) number which measures abasic (apurinic/apyrimidinic) sites per 105 base pairs in genomic DNA. Disease activity markers (albumin, CRP, ESR, Hb, WCC, platelets), Montreal phenotype of location (perianal, colon, ileum, UGIT) and other IBD medication use (steroids, azathioprine/6-MP, methotrexate, 5-ASA) were recorded. Mann Whitney U, Pearson and Spearman correlation statistical tests were performed. RESULTS: Thirteen infusions on 12 patients (7 females, 5 males) were analysed (missing data for 3 urine and 4 serum samples). Urine 8-HDOG values pre-IFX median was 1.91 (range 1.16-6.28) and post-IFX median was 3.51 (range 0.5810.53, difference P =0.065). Serum ARP numbers pre-IFX median was 9.30 (range 4.722.8) and post-IFX median was 9.4 (range 0.8-33.8, difference P=0.595). There was no correlation between serum difference and urine difference pre- and post- IFX (R= 0.546 ,P= 0.205). CRP was inversely correlated with urine difference (r= -0.645, P=0.032) with a trend towards inverse correlation with serum difference (r= -0.611, P=0.081). Pre- and post-IFX serum or urine levels were not associated with other biochemical parameters, CDAI, disease location phenotype or use of other IBD medications. CONCLUSIONS: In this pilot study, urinary 8-HDOG levels increased after IFX infusion, hypothesized to be due to DNA release and oxidative damage. Inverse correlation of 8-HDOG with CRP levels may represent evidence of therapeutic efficacy. Urine 8-HDOG may be a biomolecular marker of IFX efficacy. Further confirmatory studies are planned. Table of Main Results
Sa1307 Infliximab Modifies Circulating Reactive Oxygen Species and Restores Serum Antioxidant Potential in Inflammatory Bowel Disease Patients Luca Pastorelli, Cristian Testa, Carlo De Salvo, Luisa Spina, Gianeugenio Tontini, Nadia Munizio, Maurizio Vecchi Aim of the study: Circulating reactive oxygen species (ROS) are significantly increased during inflammatory states. ROS production can cause direct tissue damage, altering biomolecules, such as lipids, proteins and nucleic acids, and increase inflammatory responses upon activation of pro-inflammatory pathways. ROS production has been reported to play a role in eliciting the inflammatory cascade and mucosal injury characterizing Inflammatory Bowel Diseases (IBD); in fact IBD patients display elevated serum and tissue ROS and reduced levels of antioxidant enzymes, and free radical scavenger compounds have been shown to be effective in ameliorating intestinal inflammation in experimental models of colitis. Accordingly, TNFα, a key inflammatory mediator in IBD, increases ROS production. AntiTNFα monoclonal antibody therapy is indeed effective in inducing remission or reducing disease activity in IBD; however, the blockade of TNFα acts at different levels, which are yet to be fully characterized. Aim of the present study is to evaluate if anti-TNFα therapy may modify oxidoreductive state in IBD patients. Materials and methods: 42 sera were collected from 14 IBD patients (8 CD, 6 UC), before each of the first 3 Infliximab (IFX) infusions of the therapeutic induction regimen. Serum ROS were evaluated using the dROM test, spectrophotometric test based on the measurement of hydroperoxide generated by ROS; biological antioxidant potential (BAP), as a measure of plasmatic antioxidant barrier, was determined using the BAP test, colorimetric test assessing the plasmatic antioxidant power. Statistical analysis was performed by means of paired Student's t test. Results: Serum ROS levels were markedly reduced throughout IFX therapy, as observed comparing the first to the third infusion (370.49±135.58 vs. 294.46±96.94 Ucarr; p<0.005); BAP was transiently increased after the first infusion (4251.63±508.36 vs. 4950.93±460.35 mmol/l; p<0.0005), but was restored to the original level before the third infusion. Conclusions: Taken together, our data show that anti-TNFα therapy significantly modifies serum oxidative stress in IBD patients, reducing ROS production and increasing antioxidant potential, suggesting another possible mechanism through which IFX exerts its therapeutic effect.
Sa1310 Therapeutic Decision Making in Newly Diagnosed Crohn's Disease Patients Veerle J. Nuij, Judith E. Baars, Ernst J. Kuipers, Christien J. van der Woude Background and aims: Guidelines based on literature recommend a step-up approach for the induction and maintenance of remission in Crohn's disease (CD). However the same guidelines lack directions for timing these step-up decisions. Furthermore, a top-down approach is increasingly advocated under the assumption that this may prevent long-term complications. Given this discrepancy, we were interested in therapeutic decision making in current clinical practice in newly diagnosed CD patients (pts). Furthermore, we wanted to know whether the disease phenotype at diagnosis influences the number of step-up decisions during follow-up. Methods: In four general hospitals in the South-West of The Netherlands all newly diagnosed CD pts between January 1st, 2006 and January 1st, 2007 were included. End of follow-up was January 1st, 2010. Data on patient-, and disease characteristics were derived from the medical records. Therapeutic decisions after start of initial therapy were scored as follows: no change, step-down, change within therapeutic group, and step-up. Statistical analysis was performed using Chi-square tests and Cramer's V. Results: In total, 102 pts were diagnosed with CD, of whom 100 (98%) could be included (one patient died, one moved abroad). Forty-five pts (45%) were male. Median follow-up time was 40.7 months (IQR 37.5 - 43.8). In total, 227 therapeutic step-up decisions were made in 81 (81%) pts, and 19 (19%) pts underwent 24 surgical procedures. Three (3%) pts were referred to a tertiary IBD clinic. Sixty-six (66%) patients used 5-ASA as a part of initial therapy. Of the 252 therapeutic step-up decisions, 86 (34%) included start of corticosteroids, 67 (26.6%) included step-up to immunosuppressants and 46 (18.3%) included step-up to anti-TNF. The median number of step-ups per patient was 2 (range 012). Reasons for step-up decisions were mainly based on symptoms (38%) and not on endoscopy (only 13%). Pts visiting the outpatient clinic more frequently had significantly more step-ups (p < 0,001, correlation 0.729). Pts with extra-intestinal manifestations, fistulas, or perianal disease with fistulas or abscesses had a similar number of step-ups compared with pts without these manifestations. The number of visits to the outpatient clinic did not differ between these groups. Conclusions: Despite current guidelines, 5-ASA is still prescribed in the majority of newly diagnosed CD pts. However 51% of the newly diagnosed CD pts require a step-up therapy within three months after diagnosis often based on non-invasive parameters only. The most prescribed therapy for CD are corticosteroids. Overall, a large proportion of newly diagnosed patients undergo frequent medical changes. These results state that the current policy needs to be optimized. However, as we have no data on disease outcome yet, we need to be careful with this statement.
Sa1308 Anti-TNF Therapy Improves Stored Body Iron Serum Markers in Inflammatory Bowel Disease Patients Luca Pastorelli, Cristian Testa, Roberta Rigolini, Paola Giubbilini, Luisa Spina, Gianeugenio Tontini, Nadia Munizio, Carlo De Salvo, Benedetta Rampoldi, Elena Costa, Maurizio Vecchi Aim of the study: Chronic intestinal inflammation, characterizing Inflammatory Bowel Diseases (IBD), may cause profound changes in gut tissue architecture, resulting eventually in nutrient malabsorption and chronic loss of blood from gut mucosa. Moreover, the chronic inflammatory state is able to induce the activation of the reticuloendothelial system, and consequent iron sequestration. Thus, IBD patients often present iron deficiency and alterations of iron markers leading to anemia or other clinical conditions. Infliximab (IFX) is a chimeric anti-TNFα monoclonal antibody, currently used as a therapeutic option in moderate to severe IBD. Indeed effective in inducing remission or reducing disease activity, the blockade of TNFα acts at different levels, which are yet to be fully characterized. Aim of the present study is to evaluate if IFX therapy exerts direct effects of on stored body iron in IBD patients. Materials and methods: 42 sera were collected from 14 IBD patients (8 CD, 6 UC), before each IFX infusion, for the first 3 infusions of the therapeutic regimen. Serum ferritin was determined by a solid-phase two-site chemiluminescent immunometric assay, instead transferrin and CRP levels were measured by a immunoturbidimetric and iron by a colorimetric assay. Statistical analysis was performed by means of paired Student's t test. Results: Serum iron significantly increased between the first and the third IFX infusion (36.71±11.98 vs. 48.14±19.51 μg/dl, p<0.05), as well as serum total transferrin (202.57±43.11 vs. 252.29±39.90 mg/dl, p<0.01); CRP was significantly reduced (2.06±2.26 vs. 0.49±0.52 mg/ dl, p<0.05), while a trend towards ferritin decrease was detectable, although not significant (64.14±71.50 vs. 27.50±30.80 ng/ml, p=0.06). Conclusions: Taken together, our data show that anti-TNFα therapy significantly modifies serum markers of stored body iron, suggesting that, inducing mucosal healing, IFX may restore iron absorption and reduce intestinal iron loss, but also it may directly modulate the cytokine network regulating iron metabolism in the reticuloendothelial system.
AGA Abstracts
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