Clinical Course and Treatment Implications of Combination Immune Checkpoint Inhibitor-Mediated Hepatitis: A Multicentre Cohort.

BACKGROUND: Immune-related adverse events can occur after treatment with immune checkpoint inhibitors (ICI), limiting treatment persistence. We aimed to evaluate the clinical course of ICI-mediated hepatitis (IMH) associated with combination ipilimumab and nivolumab treatment. METHODS: A retrospective cohort study including consecutive patients with metastatic melanoma treated with ipilimumab and nivolumab between 2013 and 2018 was conducted at two tertiary care centres. IMH was defined by the Common Terminology Criteria for Adverse Events (CTCAE). We determined the proportion of patients developing IMH, and compared the duration, treatment patterns and outcomes, stratified by hepatitis severity. Kaplan-Meier survival analysis was used to evaluate time to hepatitis resolution, and a linear mixed-effects model was used to compare longitudinal outcomes by treatment. RESULTS: A total of 63 patients were included. Thirty-two patients (51%) developed IMH (34% Grade 1-2, 66% Grade 3-4), at a median of 34 days (IQR 20 to 43.5 days) after the first dose. Baseline FIB4 index ≥1.45 was associated with IMH (OR 3.71 [95% CI: 1.03 to 13.38], P = 0.04). Ninety-four per cent (30/32) of patients had liver enzyme normalization after a median duration of 43 days (IQR 26 to 70 days). Corticosteroid use was not associated with faster IMH resolution or less ICI discontinuation. A total of 24 patients died during the study; no deaths were attributable to hepatitis-related complications. Fifty-three per cent (17/32) of patients resumed anti-PD-1 monotherapy and three patients developed IMH recurrence. CONCLUSIONS: Approximately half of the patients treated with combination ipilimumab and nivolumab developed IMH in this cohort. However, most patients experienced uncomplicated IMH resolution.

Crohn's-like disease in a patient exposed to anti-Interleukin-17 blockade (Ixekizumab) for the treatment of chronic plaque psoriasis: a case report.

BACKGROUND: Plaque psoriasis and inflammatory bowel disease (IBD) are both chronic immune-mediated inflammatory diseases with an overlapping genetic profile and have been linked in epidemiological studies. Psoriasis and IBD share similar components in their inflammatory pathways and animal and human studies have suggested a potential role for targeting interleukin (IL)-17 with novel antibody therapies in the treatment of these diseases. These studies, while promising for psoriasis, have been associated with deterioration in patients with IBD. Post-hoc analyses of clinical trials involving Ixekizumab revealed adverse outcomes in a small cluster of patients with IBD, prompting recommendations to monitor this population with the use of this drug. CASE PRESENTATION: Forty-two year old Caucasian male with treatment-refractory chronic plaque psoriasis who developed new onset diarrheal illness and rectal bleeding following a 12 week induction period with Ixekizumab (anti-IL-17 neutralizing antibody). Colonoscopy revealed severe ulceration throughout the ascending and transcending colon. Histopathology, combined with endoscopic findings, led to a diagnosis of Crohn's-like colitis. The patient's anti-IL-17 medication was discontinued and endoscopic remission was induced with the use of corticosteroids, escalated anti-TNF therapy and eventually anti IL-12/23 neutralizing antibody (ustekinumab). CONCLUSION: Murine studies implicate IL-17 and the downstream effects of its inhibition, in the breakdown of the gut epithelial layer, the disruption of normal host immune responses and the propagation of intestinal inflammation. The increasing use of IL-17 inhibitors has led to reports of exacerbation and potential development of inflammatory bowel disease. While clinical trials have revealed clusters of new inflammatory bowel disease cases amongst psoriasis patients using an IL-17 inhibitor, there remains a lack of evidence to suggest a causal relationship. This is the first case report of de-novo severe Crohn's-like IBD in association with the use of Ixekizumab requiring rescue with escalated dosing of anti-TNF therapy and highlights the importance of close monitoring in patients being treated with IL-17 inhibitors, especially in those patients with known risk factors for inflammatory bowel disease.

The Evolution of Metastatic Colorectal Cancer Clinical Trials: Application of the ASCO Framework for Assessing Value.

Background: Phase III trials in metastatic colorectal cancer (mCRC) have collectively led to progressive advancements in patient outcomes over the past decades. This study characterizes the evolution of mCRC phase III trials through assessing the value of cancer therapy, as measured by the ASCO Value Framework. Methods: Phase III trial results of systemic therapy for mCRC published between 1980 and 2015 were identified, and their outcome, statistical significance, journal impact factor, and citation by the 2016 NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for CRC were recorded. For each trial, the net health benefit (NHB) score was calculated using the June 2015 (original) and May 2016 (revised) ASCO Value Framework: Advanced Disease. Results: There were 114 mCRC phase III trials eligible for calculation of the NHB score. Using the revised framework, the median NHB score was 4.6 (range, -30 to 43.5); 12% of trials received bonus points. Trials with statistically significant results had higher NHB scores compared with nonsignificant trials (median NHB score, 21.6 vs 2.9; P<.0001). Clinical trials cited in the NCCN Guidelines had higher NHB scores than those not cited (median score, 8.0 vs 0.3; P=.02). In multivariate linear regression analysis, the only significant predictor of high NHB score was statistically significant studies. Conclusions: The median NHB score for mCRC phase III trials was 4.6. Higher NHB scores are associated with statistically significant studies and are cited in the NCCN Guidelines, a surrogate for practice-changing trials. The 2016 ASCO Value Framework may not fully capture the benefits on an individual patient level.

UV and hydrogen peroxide treatment restores changes in innate immunity caused by exposure of fish to reuse water.

The purpose of this study was to assess the innate immunity of goldfish exposed to reuse water, and UV/H2O2-treated reuse water, using a real-time flow-through exposure system. The reuse water generated by ultrafiltration of finished wastewater from the municipal wastewater treatment plant was analyzed for the presence of a panel of 20 herbicides/fungicides and 46 pharmaceuticals and personal care products (PPCP). There was a seasonal variation in the profile and concentrations of xenobiotics in reuse water with lowest levels occurring in the summer. The innate immunity parameters assessed were cytokine (IFNγ, IL-1ß, IL-10, TNFα2), and cytokine receptor (TNFR1, TNFR2, IFNGR1, IFNGR2) gene expression, and phagocytosis of kidney leukocyte subpopulations. Assessment of innate immunity parameters was done after acute (7 days) and sub chronic (30 and 60 days) exposure to reuse water, UV/H2O2-treated reuse water, and activated carbon-treated reuse water (ACT; control), during spring, summer and fall of 2012. Temporal (acute versus sub chronic) as well as seasonal differences in innate immunity of fish exposed to reuse water were observed. The acute exposure of fish to reuse water caused significant down-regulation in cytokine gene expression in different organs of fish (kidney, spleen, liver) and phagocytic ability of different kidney leukocyte subpopulations. The immune gene expression and phagocytosis of kidney leukocytes of fish returned to ACT control levels after sub chronic exposure suggesting that fish have habituated to the reuse water exposure. The changes in gene expression after acute exposure were related to variations in the profile of xenobiotics in reuse water during different seasons. The efficiency of xenobiotic removal using UV/H2O2 ranged between 1.6 and 100% indicating that treatment of reuse water using high dose UV/H2O2 was only partially effective in removing the xenobiotics, as assessed by both chemical analyses and measurement of innate immune responsiveness of the fish. Furthermore, exposure of fish to reuse water and UV/H2O2-treated reuse water generated in the spring and fall caused greater changes in innate immunity after acute exposure, compared to fish exposed to ACT reuse water, indicating that the remediation of reuse water, should be considered in order to protect aquatic and public health.

A soluble form of the CSF-1 receptor contributes to the inhibition of inflammation in a teleost fish.

We previously reported on the identification of a novel soluble form of the CSF-1 receptor (sCSF-1R) in goldfish that induced dose-dependent down-regulation of macrophage proliferation. Herein, we report that sCSF-1R has a role beyond macrophage development, which extends into the control of cellular antimicrobial inflammatory responses in this lower vertebrate. Using an in vivo model of self-resolving peritonitis coupled to in vitro characterization of sCSF-1R activity, we show that sCSF-1R plays a role in the inhibition of inflammation which follows an initial acute phase of innate antimicrobial responses within an inflammatory site. In vitro, mature goldfish primary kidney macrophages but not monocytes up-regulated sCSF-1R expression upon direct contact with apoptotic cells. In vivo, sCSF-1R expression coincided with an increase in macrophage numbers that resulted from administration of apoptotic cells into the goldfish peritoneal cavity. This contrasted the decrease in sCSF-1R expression during zymosan-induced inflammatory responses in vivo. Subsequent experiments showed an anti-inflammatory effect for sCSF-1R. Leukocyte infiltration and ROS production decreased in a dose-dependent manner compared to zymosan-stimulated controls upon addition of increasing doses of recombinant sCSF-1R. Among others, sCSF-1R may contribute to the dual role that phagocytic macrophages play in the induction and regulation of inflammation. Overall, our results provide new insights into ancient mechanisms of inflammation control and, in particular, the evolutionary origins of the CSF-1 immune regulatory axis.