RESUMO
Both psoriasis and inflammatory bowel disease (IBD) are immunomediated diseases. Some of their therapeutic tools are monoclonal antibodies. Ixekizumab is an interleukin-17 (IL-17) inhibitor approved for the treatment of psoriasis. Cases of IBD onset have been reported in patients treated with this drug. We present the case of a 35-year-old patient with the onset of ulcerative colitis (UC) type of IBD after starting ixekizumab treatment.
RESUMO
BACKGROUND: ustekinumab has proven effective in Crohn's disease (CD). However, some patients will partially respond or lose response over time. Data supporting the effectiveness of dose escalation in this scenario is scarce. AIM: to evaluate the effectiveness of ustekinumab dose escalation in CD. METHODS: patients with active CD (Harvey-Bradshaw ≥ 5) who had received intravenous (IV) induction and at least a subcutaneous (SC) dose were included in this retrospective observational study. Ustekinumab dose was escalated, either via shortening of the interval to six or four weeks or IV reinduction plus shortening to every four weeks. RESULTS: ninety-one patients were included, and ustekinumab dose was escalated after a median of 35 weeks of treatment. At week 16 after intensification, steroid-free clinical response and remission were observed in 62.6 % and 25.3 % of patients, respectively. Systemic corticosteroids were discontinued in 46.7 % of patients who were on corticosteroids at baseline. Follow-up data beyond week 16 were available for 78 % of patients; at the last visit, 66.2 % and 43.7 % were in steroid-free clinical response and remission, respectively. After a median follow-up of 64 weeks, 81 % of patients were still treated with ustekinumab. Adverse events were reported in 4.3 % of patients; these were all mild and did not lead to hospitalization or discontinuation of treatment. Five patients (5.5 %) underwent surgical resection, with no immediate postsurgical complications. CONCLUSION: ustekinumab dose escalation was effective in recapturing response in over half of the patients. These findings suggest that dose escalation should be considered in patients who experience loss or partial response to the standard maintenance.
Assuntos
Doença de Crohn , Ustekinumab , Humanos , Ustekinumab/efeitos adversos , Doença de Crohn/tratamento farmacológico , Indução de Remissão , Estudos Retrospectivos , Corticosteroides/uso terapêutico , Resultado do TratamentoRESUMO
BACKGROUND: tofacitinib is a Janus kinase inhibitor approved for the treatment of moderate-severe ulcerative colitis (UC). This study aimed to evaluate its efficacy in a real-life setting. METHODS: a retrospective and multicenter observational study was performed with UC patients treated with tofacitinib. Short and long-term treatment effectiveness, treatment survival, need for dose escalation and safety were analyzed. Clinical response and remission were defined in accordance with the partial Mayo score. RESULTS: seventy-four patients were included, 98.3 % had received prior biological treatment, 55.4 % with three or more biologicals and up to 64.9% with two or three different mechanisms of action. Clinical remission and response rates were 37.8 % and 77 % at eight weeks, and 41.8 % and 70.1 % at 16 weeks. With regard to non-responders at eight weeks, 37.5 % achieved a delayed clinical response at 16 weeks. Mean treatment duration was 19 months (95 % CI: 16-22), with a treatment survival of 56 % at 28 months, and remission and response rates at 24 months of 53.8 % and 61.5 %. Twenty-three treatments were withdrawn, most of them (18) during the induction period. There were adverse events in a quarter of the patients; only four were severe and led to treatment discontinuation. CONCLUSION: tofacitinib has a demonstrated efficacy in clinical practice to induce and maintain clinical response in treatment-refractory UC patients, with an acceptable safety profile.
Assuntos
Colite Ulcerativa , Colite Ulcerativa/induzido quimicamente , Colite Ulcerativa/tratamento farmacológico , Humanos , Piperidinas/efeitos adversos , Pirimidinas/efeitos adversos , Estudos RetrospectivosRESUMO
Liver cirrhosis is a disease related to numerous severe complications such as portal hypertension or collateral circulation. Varices that are located outside the gastroesophageal region (ectopic varices) such as the anorectal region, colon, ileum or gallbladder are unusual. In many cases, they are related to the existence of portal vein thrombosis. We report the case of a patient with a severe hemorrhage of gallbladder varices due to alcohol-related cirrhosis.
Assuntos
Vesícula Biliar/irrigação sanguínea , Hemorragia/etiologia , Cirrose Hepática/complicações , Varizes/complicações , Evolução Fatal , Vesícula Biliar/diagnóstico por imagem , Hemoperitônio/diagnóstico por imagem , Hemoperitônio/terapia , Hemorragia/diagnóstico por imagem , Humanos , Cirrose Hepática/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Varizes/diagnóstico por imagemAssuntos
Pancreatite , Doenças Vasculares , Doença Aguda , Humanos , Pâncreas , Pancreatite/etiologiaAssuntos
Varizes Esofágicas e Gástricas , Síndrome da Veia Cava Superior , Varizes , Varizes Esofágicas e Gástricas/complicações , Hemorragia , Humanos , Síndrome da Veia Cava Superior/diagnóstico por imagem , Síndrome da Veia Cava Superior/etiologia , Varizes/complicações , Varizes/diagnóstico por imagemAssuntos
Neoplasias Colorretais/genética , Genes BRCA1 , Doenças Inflamatórias Intestinais/genética , Síndromes Neoplásicas Hereditárias/genética , Adenocarcinoma/genética , Adenocarcinoma/cirurgia , Adulto , Idade de Início , Anti-Inflamatórios/uso terapêutico , Azatioprina/uso terapêutico , Neoplasias da Mama/genética , Colite Ulcerativa/genética , Neoplasias do Colo/genética , Neoplasias do Colo/cirurgia , Feminino , Predisposição Genética para Doença , Humanos , Masculino , Mesalamina/uso terapêutico , Proctocolectomia RestauradoraAssuntos
Anticorpos Monoclonais Humanizados/efeitos adversos , Antineoplásicos Imunológicos/efeitos adversos , Colite/induzido quimicamente , Neoplasias Ósseas/secundário , Colite/diagnóstico por imagem , Colite/tratamento farmacológico , Colite Ulcerativa/diagnóstico por imagem , Colonoscopia , Humanos , Neoplasias Pulmonares/secundário , Masculino , Melanoma/tratamento farmacológico , Melanoma/secundário , Pessoa de Meia-Idade , Neoplasias Cutâneas/tratamento farmacológicoAssuntos
Neoplasias dos Ductos Biliares/diagnóstico por imagem , Ductos Biliares Extra-Hepáticos/diagnóstico por imagem , Carcinoma de Células Escamosas/diagnóstico por imagem , Idoso , Neoplasias dos Ductos Biliares/patologia , Ductos Biliares Extra-Hepáticos/patologia , Carcinoma de Células Escamosas/patologia , Feminino , Humanos , Biópsia Guiada por Imagem/métodos , Imageamento por Ressonância MagnéticaAssuntos
Doenças Autoimunes do Sistema Nervoso/etiologia , Doenças Cerebelares/etiologia , Doença de Crohn/complicações , Doença Aguda , Adulto , Anticorpos Antinucleares/sangue , Doenças Autoimunes do Sistema Nervoso/diagnóstico por imagem , Doenças Autoimunes do Sistema Nervoso/imunologia , Ataxia Cerebelar/etiologia , Doenças Cerebelares/diagnóstico por imagem , Doenças Cerebelares/imunologia , Doença de Crohn/imunologia , Diplopia/etiologia , Humanos , Imageamento por Ressonância Magnética , Masculino , Neuroimagem , Reflexo Anormal , Tomografia Computadorizada por Raios XAssuntos
Equinococose Hepática/complicações , Hipertensão Portal/etiologia , Antagonistas Adrenérgicos beta/uso terapêutico , Adulto , Albendazol/uso terapêutico , Anti-Helmínticos/uso terapêutico , Angiografia por Tomografia Computadorizada , Equinococose Hepática/diagnóstico por imagem , Equinococose Hepática/cirurgia , Procedimentos Cirúrgicos Eletivos , Varizes Esofágicas e Gástricas/etiologia , Hemorragia Gastrointestinal/etiologia , Hepatectomia , Humanos , Imageamento por Ressonância Magnética , Masculino , RecidivaRESUMO
BACKGROUND: Liver enzyme (LE) elevation is a common finding in routine blood analysis. There is very little information on the most prevalent causes of these alterations in our population. In addition, a number of tests and several visits to the specialist are required to reach a diagnosis. For these reasons, we designed a protocol to streamline the evaluation of patients with LE elevations in a single-act office visit. METHODS: From March 2008 until June 2010, we studied all patients with incidental LE elevation (isolated transaminase elevation, combined elevation of alkaline phosphatase [FA] and gamma-glutamyl transpeptidase [GGT], or isolated elevation of GGT) who were referred by their primary care physicians. At the time of referral, a complete biochemistry analysis was performed (LE, viral serology, autoantibodies, ceruloplasmin, iron metabolism, alpha-1-antitrypsin and thyroid hormones) and the patients underwent an abdominal ultrasound scan on the day of the office evaluation by the hepatologist. RESULTS: A total of 427 patients were included in our study. The most common cause of transaminase elevation was non-alcoholic fatty liver disease (NAFLD) (40%), followed by alcohol intake (17%), and hepatitis C virus infection (13%). Elevated GGT levels were most commonly related to NAFLD (30%), closely followed by alcohol intake (27%), and hepatotoxicity (8%). Combined elevation of GGT and FA was associated with NAFLD (21%), alcohol (17%), and hepatotoxicity (11%). Self-limited elevation was seen in 9% of the patients and we could not identify a definite cause in 11%. A definitive diagnosis was reached in 79% of the patients. CONCLUSIONS: The single-act office visit has proven to be efficient, yielding a diagnosis in most of the patients. The most common cause of elevated LE was NAFLD. Transaminase elevation must be confirmed before a more thorough work-up is started.
Assuntos
Fosfatase Alcalina/sangue , Hepatopatias/sangue , Hepatopatias/enzimologia , Fígado/enzimologia , Transaminases/sangue , gama-Glutamiltransferase/sangue , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Visita a Consultório Médico , Adulto JovemRESUMO
Inflammatory bowel disease is accompanied by extraintestinal manifestations in a high percentage of patients. Cutaneous lesions are the second most prevalent of these manifestations, and within these, metastatic Crohn's disease is one of the least common, being the least frequent specific cutaneous manifestation of Crohn's disease. This entity includes cutaneous and subcutaneous lesions with a non-caseating granulomatous appearance on histological analysis identical to that of Crohn's disease. These lesions are not found adjacent to the digestive tract. Due to the low prevalence of these manifestations, conclusive trials on the treatment of choice have not been performed and there is no well-defined therapeutic strategy. Distinct therapies with varying results have been reported. We report the case of a female patient with longstanding and complex Crohn's disease who developed metastatic cutaneous manifestations while receiving adalimumab. The cutaneous manifestations responded well to dose intensification of this drug. A review of the literature is provided.