Switching from intravenous to subcutaneous infliximab and vedolizumab in patients with inflammatory bowel disease: impact on trough levels, day hospital visits, and medical expenses.

OBJECTIVE: Subcutaneous (SC) infliximab (IFX) and vedolizumab (VDZ) have recently become available. We aimed to examine the impact of switching from intravenous (IV) to SC IFX and VDZ in patients with inflammatory bowel disease (IBD) on costs, the day hospital burden, trough levels, and clinical outcomes. METHODS: Our study comprised the cohort of IBD patients receiving IV IFX or VDZ at our hospital in 2022. We evaluated costs, day hospital visits, trough levels, biochemical markers, relapse rates, and self-report outcomes until Jun 30th 2023. RESULTS: Of 114 patients, 18 continued IV therapy, 80 were switched to SC therapy, and 16 were inductions. Eighty-eight (90%) remained in steroid-free remission with no difference between the IV or SC groups. The mean IFX trough level changed from 8.2 ± 4.5 µg/ml to 14.5 ± 5.9 µg/ml, p < 0.001, and the VDZ trough level from 14.7 ± 7.1 mg/ml to 26.5 ± 13.8 mg/ml, p < 0.001. The average yearly costs of infusions and injections per patient were 2 580 € and 7 482 € for IFX and 15 990 € and 13 101 € for VDZ. The annual reduction of day hospital visits was 6,9 per patient. CONCLUSIONS: IV and SC IFX and VDZ are equally effective in maintaining remission in IBD, but SC administration reduces day hospital visits and results in higher trough levels. SC VDZ is less and SC IFX more expensive than IV therapy. Further studies are needed to assess optimal dosing and separate trough levels for SC therapy.

Moth versus fly: a preliminary study of the pollination mode of two species of endemic Asteraceae from St Helena (Commidendrum robustum and C. rugosum) and its conservation implications.

Commidendrum robustum (Roxb.) DC. (St Helena gumwood) and C. rugosum (Dryand.) DC. (St Helena scrubwood) are ecologically important, endemic woody Asteraceae from the isolated South Atlantic island of St Helena. Once very abundant, they now exist in sparse fragmented populations due to 500 years of environmental destruction. They are sister taxa that evolved on the island and are reported to hybridise. Commidendrum rugosum has a saucer-like erect capitulum, whereas C. robustum has a somewhat globular hanging capitulum. Using daytime timelapse photography to follow capitula through their life cycle, we found that C. rugosum appears to be myophilous, visited largely by flies (including the endemic syrphid, Sphaerophoria beattiei Doesburg & Doesburg) and occasionally by Lepidoptera. Commidendrum robustum, on the other hand, although visited by flies, strongly attracts moths (especially noted at the Millennium Forest site). Our data suggest that moth visits may reduce visits from flies due to the sensitivity of flies to interference by other insects. We conclude that C. robustum may have a mixed syndrome of myophily/phalaenophily and that there is apparently some divergence of the pollination niche between the two species. Its potential in attracting moths, coupled with its former abundance, suggests that it may have been a major food source for adults of the numerous endemic moths. Pollinator activity was measured by insect visitation rates (mean visits per capitulum per day, V) and insect residence time (mean pollinator kiloseconds per capitulum per day, R). Both are higher for C. robustum (C. rugosum, V = 16.4, R = 3.101; C. robustum, V = 34.0, R = 8.274), reflecting the abundance of moths on the capitula at the Millennium Forest site. The conservation implications of the pollination mode are that: (1) there is considerable pollinator activity on the capitula and pollination is not currently a limiting factor for plant reproduction; (2) gene exchange between geographically-isolated populations of C. rugosum is likely to be minimal due to the apparent reliance of the species for pollination on small flies (especially Sphaerophoria beattiei), which are believed to be not effective as pollinators over long distances (> 1 km). A possible exception is the strong-flying drone-fly, Eristalis tenax Linn. which, although not as abundant as Sphaerophoria, does visit the flowers; (3) there is considerable overlap between the two species in flower visitors and interspecific pollen transfer is possible where the two species grow intermixed (which has potential positive and negative implications for species survival).