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1.
Am J Gastroenterol ; 2024 Jul 15.
Artigo em Inglês | MEDLINE | ID: mdl-39008539

RESUMO

BACKGROUND: A treat-to-target strategy for inflammatory bowel disease (IBD) recommends iterative treatment adjustments to achieve clinical and endoscopic remission. In asymptomatic patients with ongoing endoscopic activity, the risk/benefit balance of this approach is unclear, particularly with prior exposure to advanced therapies. METHODS: Using the RAND/University of California Los Angeles Appropriateness Method, 9 IBD specialists rated appropriateness of changing therapy in 126 scenarios of asymptomatic patients with ulcerative colitis and Crohn's disease and active endoscopic disease. Disease extent and behavior, prior treatment, prior complications, and recent disease progression were considered, as were factors that might influence decision-making, including age and pregnancy. Ratings were collected through anonymous survey, discussed at an in-person meeting, and finalized in a second anonymous survey. RESULTS: Panelists rated change in therapy as appropriate (i.e., expected benefit sufficiently outweighs potential harms from continuing therapy) in 96/126 scenarios, generally in patients with progressive, complicated, and/or extensive disease, while changing therapy was rated uncertain in 27 scenarios of mild and/or stable disease. Changing therapy was rated inappropriate in ulcerative colitis patients with mild and stable disease previously exposed to ≥3 therapies or with improved endoscopic activity, and in Crohn's disease patients with only scattered aphthous ulcers. The validated threshold for disagreement was not crossed for any scenario. Patient age older than 65 years and a plan for pregnancy in the next year might influence decision-making in some settings. DISCUSSION: Appropriateness ratings can help guide clinical decision-making about changing therapy to achieve endoscopic remission in asymptomatic patients with IBD until data from ongoing randomized studies are available.

2.
Scand J Gastroenterol ; 57(2): 197-205, 2022 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-34919496

RESUMO

Increased interest in cannabis as a potential treatment and/or adjuvant therapy for inflammatory bowel disease (IBD) has been driven by patients with refractory disease seeking relief as well those who desire alternatives to conventional therapies. Available data have shown a potential role of cannabis as a supportive medication, particularly in pain reduction; however, it remains unknown whether cannabis has any impact on the underlying inflammatory process of IBD. The purpose of this review article is to summarize the available literature concerning the use of cannabis for the treatment of IBD and highlight potential areas for future study.


Assuntos
Cannabis , Colite Ulcerativa , Doença de Crohn , Doenças Inflamatórias Intestinais , Maconha Medicinal , Cannabis/efeitos adversos , Colite Ulcerativa/tratamento farmacológico , Doença de Crohn/tratamento farmacológico , Humanos , Doenças Inflamatórias Intestinais/tratamento farmacológico , Maconha Medicinal/uso terapêutico
3.
Clin Gastroenterol Hepatol ; 17(9): 1655-1668.e3, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30928454

RESUMO

BACKGROUND & AIMS: Therapeutic drug monitoring (TDM) is widely available for biologic therapies in patients with inflammatory bowel disease (IBD). We reviewed current data and provided expert opinion regarding the clinical utility of TDM for biologic therapies in IBD. METHODS: We used a modified Delphi method to establish consensus. A comprehensive literature review was performed regarding the use of TDM of biologic therapy in IBD and presented to international IBD specialists. Subsequently, 28 statements on the application of TDM in clinical practice were rated on a scale of 1 to 10 (1 = strongly disagree and 10 = strongly agree) by each of the panellists. Statements were accepted if 80% or more of the participants agreed with a score ≥7. The remaining statements were discussed and revised based on the available evidence followed by a second round of voting. RESULTS: The panel agreed on 24 (86%) statements. For anti-tumor necrosis factor (anti-TNF) therapies, proactive TDM was found to be appropriate after induction and at least once during maintenance therapy, but this was not the case for the other biologics. Reactive TDM was appropriate for all agents both for primary non-response and secondary loss of response. The panellists also agreed on several statements regarding TDM and appropriate drug and anti-drug antibody (ADA) concentration thresholds for biologics in specific clinical scenarios. CONCLUSION: Consensus was achieved towards the utility of TDM of biologics in IBD, particularly anti-TNF therapies. More data are needed especially on non-anti-TNF biologics to further define optimal drug concentration and ADA thresholds as these can vary depending on the therapeutic outcomes assessed.


Assuntos
Anticorpos/imunologia , Monitoramento de Medicamentos/normas , Fármacos Gastrointestinais/uso terapêutico , Fatores Imunológicos/uso terapêutico , Doenças Inflamatórias Intestinais/tratamento farmacológico , Inibidores do Fator de Necrose Tumoral/uso terapêutico , Anticorpos Monoclonais Humanizados/imunologia , Anticorpos Monoclonais Humanizados/uso terapêutico , Produtos Biológicos/imunologia , Produtos Biológicos/uso terapêutico , Técnica Delphi , Fármacos Gastrointestinais/imunologia , Humanos , Fatores Imunológicos/imunologia , Natalizumab/imunologia , Natalizumab/uso terapêutico , Resultado do Tratamento , Inibidores do Fator de Necrose Tumoral/imunologia , Ustekinumab/imunologia , Ustekinumab/uso terapêutico
4.
Clin Gastroenterol Hepatol ; 16(11): 1829-1831, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-29505910

RESUMO

Randomized controlled trials (RCTs) have demonstrated that therapies targeting tumor necrosis factor (TNF) and α4ß7 integrin are effective when given as monotherapy in inducing and/or maintaining remission in patients with ulcerative colitis (UC) or Crohn's disease (CD), but data from RCTs are less clear on whether concomitant immunomodulator (IM) therapy confers additional benefit. In CD, RCT data are mixed,1,2 as are results of systematic reviews and meta-analyses, showing no benefit overall,3 minimal benefit with individual agents,4 and comparative benefit over some monotherapies but not others.5 For example, concomitant azathioprine with infliximab is more effective than either drug alone in patients with CD naive to both drugs,2 but whether combination therapy is more effective than monotherapy with infliximab in nonnaive patients, or with other approved biologic drugs in any population, remains unknown. In UC, RCTs have shown that the benefit may be limited to specific populations,6 whereas systematic reviews suggest no benefit at all.7.


Assuntos
Quimioterapia Combinada/métodos , Fatores Imunológicos/uso terapêutico , Doenças Inflamatórias Intestinais/tratamento farmacológico , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Adulto Jovem
5.
Clin Gastroenterol Hepatol ; 14(9): 1302-9, 2016 09.
Artigo em Inglês | MEDLINE | ID: mdl-27189916

RESUMO

BACKGROUND & AIMS: The availability of tests for blood concentrations of anti-tumor necrosis factor (TNF) agents and antibodies against these drugs could improve dose selection for patients with inflammatory bowel disease (IBD). However, there is little consensus on when to test and how to interpret test results. We used the RAND/UCLA Appropriateness Method to determine when these tests are appropriate and how to clinically interpret their results. METHODS: We conducted a systematic literature search in November 2013 to identify observational or experimental studies of the measurement of anti-TNF drug and antibody concentrations in patients with IBD and interpretation of their results. We developed 35 scenarios that assessed the appropriateness of testing and 143 scenarios that addressed clinical strategies in response to test results, and presented the findings to an expert panel. The appropriateness of each scenario was rated before and after an in-person meeting with the panel. Panelists rated the appropriateness of various clinical management options including changing therapy within class, switching out of class, adjusting drug dose or interval, adding or adjusting concomitant immune modulators, and doing nothing for each of 6 permutations of high versus low drug concentrations and high, low, or undetectable antibody concentrations. Disagreement was assessed using a validated index. RESULTS: Assessment of anti-TNF drug and antibody concentrations was rated appropriate at the end of induction therapy in primary nonresponders, in secondary nonresponders, at least once during the first year of maintenance therapy, and following a drug holiday. Routine assessment in responders at the end of induction was rated uncertain. In nearly all scenarios, escalation of drug dosing was rated appropriate when drug concentration was low in the absence of antibodies, and switching within class was rated appropriate when antibodies were present. Other recommendations depended on the specific clinical scenario for which the test was obtained. CONCLUSIONS: Based on the RAND/UCLA Appropriateness Method of analysis, an expert panel recommends testing for drug and antibody concentrations in many clinical scenarios. The appropriate timing and best way to respond to anti-TNF drug and antibody testing for IBD depends on the specific clinical scenario. These recommendations can help guide clinicians to best optimize anti-TNF therapy.


Assuntos
Anticorpos/sangue , Monitoramento de Medicamentos/métodos , Fatores Imunológicos/sangue , Doenças Inflamatórias Intestinais/tratamento farmacológico , Fator de Necrose Tumoral alfa/antagonistas & inibidores , Fator de Necrose Tumoral alfa/imunologia , Humanos , Fatores de Tempo
6.
Clin Gastroenterol Hepatol ; 13(13): 2233-40.e1-2; quiz e177-8, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26142167

RESUMO

BACKGROUND & AIMS: There is debate over whether patients with Crohn's disease who start anti-tumor necrosis factor (TNF) therapy after failed immunomodulator therapy should continue to receive concomitant immunomodulators. We conducted a meta-analysis of subgroups from randomized controlled trials (RCTs) of anti-TNF agents to compare the efficacy and safety of concomitant immunomodulator therapy vs anti-TNF monotherapy. METHODS: We performed a systematic review of literature published from 1980 through 2008 and identified 11 RCTs of anti-TNF agents in patients with luminal or fistulizing Crohn's disease. We excluded RCTs of patients who were naive to anti-TNF and immunomodulator therapy. The primary end points were clinical response at weeks 4-14 and 24-30 and remission at weeks 24-30. Secondary end points included infusion site or injection site reactions and selected adverse events. A priori subgroup analyses were performed to evaluate fistula closure and the efficacy and safety of combination therapy with different anti-TNF agents. RESULTS: Overall, combination therapy was no more effective than monotherapy in inducing 6-month remission (odds ratio [OR], 1.02; 95% confidence interval [CI], 0.80-1.31), inducing a response (OR, 1.08; 95% CI, 0.79-1.48), maintaining a response (OR, 1.53; 95% CI, 0.67-3.49), or inducing partial (OR, 1.25; 95% CI, 0.84-1.88) or complete fistula closure (OR, 1.10; 95% CI, 0.68-1.78). In subgroup analyses of individual anti-TNF agents, combination therapy was not more effective than monotherapy in inducing 6-month remission in those treated with infliximab (OR, 1.73; 95% CI, 0.97-3.07), adalimumab (OR, 0.88; 95% CI, 0.58-1.35), or certolizumab (OR, 0.93; 95% CI, 0.65-1.34). Overall, combination therapy was not associated with an increase in adverse events, but inclusion of infliximab was associated with fewer injection site reactions (OR, 0.46; 95% CI, 0.26-0.79.) CONCLUSIONS: On the basis of a meta-analysis, continued use of immunomodulator therapy after starting anti-TNF therapy is no more effective than anti-TNF monotherapy in inducing or maintaining response or remission. RCTs are needed to adequately assess the efficacy of continued immunomodulator therapy after anti-TNF therapy is initiated.


Assuntos
Doença de Crohn/tratamento farmacológico , Fatores Imunológicos/administração & dosagem , Fatores Imunológicos/efeitos adversos , Fator de Necrose Tumoral alfa/antagonistas & inibidores , Quimioterapia Combinada/efeitos adversos , Quimioterapia Combinada/métodos , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/epidemiologia , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/patologia , Humanos , Placebos/administração & dosagem , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento
7.
Aliment Pharmacol Ther ; 57(2): 205-214, 2023 01.
Artigo em Inglês | MEDLINE | ID: mdl-36377259

RESUMO

BACKGROUND: Crohn's disease requires effective patient-clinician communication for successful illness and medication management. Shared decision making (SDM) has been suggested to improve communication around early intensive therapy. However, effective evidence-based SDM interventions for Crohn's disease are lacking, and the impact of SDM on Crohn's disease decision making and choice of therapy is unclear. AIM: To test the impact of SDM on choice of therapy, quality of the decision and provider trust compared to standard Crohn's disease care. METHODS: We conducted a multi-site cluster randomised controlled trial in 14 diverse gastroenterology practices in the US. RESULTS: A total of 158 adult patients with Crohn's disease within 15 years of their diagnosis, with no prior Crohn's disease complications, and who were candidates to receive immunomodulators or biologics, participated in the study. Among these, 99 received the intervention and 59 received standard care. Demographics were similar between groups, although there were more women assigned to standard care, and a slightly shorter disease duration among those in the intervention group. Participants in the intervention group more frequently chose combination therapy (25% versus 5% control, p < 0.001), had a significantly lower decisional conflict (p < 0.05) and had greater trust in their provider (p < 0.05). CONCLUSIONS: With rapidly expanding medication choices for Crohn's disease and slow uptake of early intensive therapy, SDM can personalise treatment strategies and has the potential to move the field of Crohn's disease management forward with an ultimate goal of consistently treating this disease early and intensively in appropriate patients. TRIAL REGISTRATION: Evaluating a Shared Decision Making Program for Crohn's Disease, ClinicalTrials.gov Identifier NCT02084290 https://clinicaltrials.gov/ct2/show/NCT02084290.


Assuntos
Doença de Crohn , Adulto , Humanos , Feminino , Doença de Crohn/tratamento farmacológico , Tomada de Decisão Compartilhada , Tomada de Decisões
8.
Dig Dis Sci ; 61(8): 2160-2161, 2016 08.
Artigo em Inglês | MEDLINE | ID: mdl-27343039
9.
Clin Gastroenterol Hepatol ; 8(8): 655-9, 2010 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-20451665

RESUMO

BACKGROUND & AIMS: There is no consensus on the appropriateness of concomitant immunomodulators with anti-tumor necrosis factor (TNF) therapy for Crohn's disease. Some patients benefit from concomitant immunomodulators, but concerns related to infections and lymphoma risk have dampened enthusiasm for this approach. We applied the RAND/University of California Los Angeles Appropriateness Method toward establishing appropriateness of concomitant immunomodulators and anti-TNF therapies for Crohn's disease. METHODS: A literature review was conducted regarding efficacy and safety of concomitant immunomodulators in the setting of anti-TNF therapy for Crohn's disease and presented to the Building Research in Inflammatory Bowel Disease Globally group, a globally diverse panel of 13 gastroenterologists clinically experienced in inflammatory bowel disease. A total of 134 scenarios were constructed using several clinical variables. Panelists used a modified Delphi method to rate the appropriateness of concomitant immunomodulators, and met to discuss and re-rate appropriateness. Disagreement was assessed using a validated index. RESULTS: Concomitant immunomodulators were generally rated appropriate for 63 scenarios, uncertain for 60 scenarios, and inappropriate for 11 scenarios. In general, concomitant immunomodulators were appropriate for those with extensive disease, shorter duration of disease, perianal involvement, prior surgery, females, and older patients (>26 y). Concomitant immunomodulators were generally rated inappropriate for young males, and in some scenarios involving uncomplicated disease. Smoking and the particular anti-TNF medication did not influence ratings. Disagreement was observed in 6 of 134 scenarios. CONCLUSIONS: The appropriateness of concomitant immunomodulators with anti-TNF therapy for Crohn's disease was determined through a modified Delphi panel approach based on expert interpretation of the available literature. Clinicians should consider multiple factors when considering concomitant immunomodulators with anti-TNF treatment.


Assuntos
Doença de Crohn/tratamento farmacológico , Fatores Imunológicos/administração & dosagem , Fatores Imunológicos/efeitos adversos , Fator de Necrose Tumoral alfa/antagonistas & inibidores , Adalimumab , Adulto , Idoso , Idoso de 80 Anos ou mais , Anticorpos Monoclonais/administração & dosagem , Anticorpos Monoclonais/efeitos adversos , Anticorpos Monoclonais Humanizados , Certolizumab Pegol , Doença de Crohn/complicações , Feminino , Humanos , Fragmentos Fab das Imunoglobulinas/administração & dosagem , Fragmentos Fab das Imunoglobulinas/efeitos adversos , Infecções/induzido quimicamente , Infliximab , Linfoma/induzido quimicamente , Masculino , Pessoa de Meia-Idade , Polietilenoglicóis/administração & dosagem , Polietilenoglicóis/efeitos adversos , Resultado do Tratamento
10.
World J Gastroenterol ; 14(3): 354-77, 2008 Jan 21.
Artigo em Inglês | MEDLINE | ID: mdl-18200659

RESUMO

Crohn's disease (CD) and ulcerative colitis (UC) are chronic inflammatory diseases of the gastrointestinal tract. While a cure remains elusive, both can be treated with medications that induce and maintain remission. With the recent advent of therapies that inhibit tumor necrosis factor (TNF) alpha the overlap in medical therapies for UC and CD has become greater. Although 5-ASA agents have been a mainstay in the treatment of both CD and UC, the data for their efficacy in patients with CD, particularly as maintenance therapy, are equivocal. Antibiotics may have a limited role in the treatment of colonic CD. Steroids continue to be the first choice to treat active disease not responsive to other more conservative therapy; non-systemic steroids such as oral and rectal budesonide for ileal and right-sided CD and distal UC respectively are also effective in mild-moderate disease. 6-mercaptopurine (6-MP) and its prodrug azathioprine are steroid-sparing immunomodulators effective in the maintenance of remission of both CD and UC, while methotrexate may be used in both induction and maintenance of CD. Infliximab and adalimumab are anti-TNF agents approved in the US and Europe for the treatment of Crohn's disease, and infliximab is also approved for the treatment of UC.


Assuntos
Doenças Inflamatórias Intestinais/terapia , Ácidos Aminossalicílicos/uso terapêutico , Animais , Antibacterianos/uso terapêutico , Anti-Inflamatórios não Esteroides/uso terapêutico , Anticorpos Monoclonais/imunologia , Anticorpos Monoclonais/uso terapêutico , Remoção de Componentes Sanguíneos , Ensaios Clínicos como Assunto , Curcumina/uso terapêutico , Humanos , Fatores Imunológicos/uso terapêutico , Doenças Inflamatórias Intestinais/imunologia , Peptídeos e Proteínas de Sinalização Intercelular/uso terapêutico , Nicotina/uso terapêutico , Agonistas Nicotínicos/uso terapêutico , Probióticos/uso terapêutico , Indução de Remissão , Esteroides/uso terapêutico , Trichuris/metabolismo
11.
Ann Gastroenterol ; 30(4): 468-470, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28655990

RESUMO

Clostridium septicum (C. septicum) aortitis is a rare condition frequently associated with colon adenocarcinoma and carries a poor prognosis. We report the case of a 66-year-old man who presented with abdominal pain, blood in the stool, fever and chills. Laboratory tests were significant for leukocytosis and microcytic anemia. Abdominal imaging revealed a right colon mass and aortitis. Colonoscopy confirmed the right colon mass and also discovered a rectal mass, both adenocarcinomas. Treatment consisted of antibiotics, aortic repair, right hemi-colectomy and later trans-anal excision of the rectal mass. Blood cultures and the aortic specimen grew C. septicum. The patient improved and was doing well in follow up.

12.
Inflamm Bowel Dis ; 22(6): 1418-24, 2016 06.
Artigo em Inglês | MEDLINE | ID: mdl-27057680

RESUMO

BACKGROUND: Consensus on what constitutes a quality colonoscopy report for patients with inflammatory bowel disease (IBD) is lacking. We developed a template for quality colonoscopy reporting that can be used broadly by endoscopists. METHODS: After a literature review of topics relevant to colonoscopy reporting, members of the Building Research in Inflammatory Bowel Disease Globally (BRIDGe) group and 2 external experts proposed candidate reporting elements. The RAND/University of California, Los Angeles appropriateness method was applied to rate the importance and feasibility of elements for inclusion in colonoscopy reports for patients with IBD. Panelists used the modified Delphi method to anonymously rate the importance and feasibility of candidate elements on a 1-to-9 scale (1-3: not important/feasible, 4-6: moderately important/feasible, 7-9: very important/feasible). Disagreement was assessed using a validated index. The panelists then met in person for discussion followed by a second round of voting. Elements rated a median of 7 or higher on importance after rerating were retained. RESULTS: One hundred two reporting elements were proposed. A total of 48 elements were retained across the four themes of "disease background," "findings and interventions," "Crohn's disease with an ileocolonic anastomosis," and "pouchoscopy." CONCLUSIONS: A comprehensive list of recommended elements for quality IBD colonoscopy reporting stratified by clinical scenario has been described, using a rigorous and evidence-based approach. These elements can be incorporated into endoscopy reporting software platforms. Standardized endoscopy reporting may improve the quality of care in IBD.


Assuntos
Colite Ulcerativa/diagnóstico por imagem , Colo/cirurgia , Colonoscopia , Doença de Crohn/diagnóstico por imagem , Documentação/normas , Íleo/cirurgia , Anastomose Cirúrgica , Bolsas Cólicas , Consenso , Doença de Crohn/cirurgia , Técnica Delphi , Humanos , Proctocolectomia Restauradora , Literatura de Revisão como Assunto
13.
Gastroenterol Hepatol (N Y) ; 4(10): 713-20, 2008 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-21960891

RESUMO

In March 2008, a roundtable discussion was convened by the inflammatory bowel disease (IBD) specialist panel the BRIDGe (Building Resources and Research in IBD Globally) group, which consists of junior faculty gastroenterologists who have undergone advanced fellowship training at IBD referral centers in the United States, Canada, the United Kingdom, and Australia. An agenda was formulated to discuss three current controversies in Crohn's disease management: the role of 5-aminosalicylates, the use of biologic combination therapy versus monotherapy, and the use of step-up therapy versus top-down therapy for Crohn's disease. The aim of the meeting was three-fold: to review the data pertaining to each topic; to collect opinions from the participants as to their analysis of the literature and their current practice; and, where possible, to formulate recommendations of current best practice given the available evidence. This manuscript summarizes the discussions on these three areas of controversy in the current management of Crohn's disease.

14.
Am J Gastroenterol ; 102(8): 1765-80, 2007 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-17488249

RESUMO

Colon ischemia (CI) is the most common form of ischemic injury of the gastrointestinal tract. Determining the precise incidence of CI is a challenging task, because of its often brief, mild nature, and frequent spontaneous resolution, as well as its misdiagnosis as other diseases. While many underlying disease conditions may predispose patients to CI, an important and possibly overlooked etiology is that of pharmacologically induced alterations of colonic blood flow. This review details the pharmacologic agents known to be associated with CI; when possible, their mechanisms of action are described. The aim of this paper is to highlight this often unrecognized cause of CI, thereby helping physicians to be aware of the association, to recognize its occurrence promptly, and to possibly reduce morbidity and mortality.


Assuntos
Colo/irrigação sanguínea , Antibacterianos/efeitos adversos , Antineoplásicos/efeitos adversos , Depressores do Apetite/efeitos adversos , Neoplasias do Colo/tratamento farmacológico , Constipação Intestinal/induzido quimicamente , Digitalis/efeitos adversos , Humanos , Isquemia/induzido quimicamente , Descongestionantes Nasais/efeitos adversos
15.
Gastroenterol Clin North Am ; 35(4): 757-73, 2006 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-17129812

RESUMO

The pharmacology of each biologic agent is important regarding the dose required to achieve benefits, duration of therapeutic effect, and the induction of immunogenicity. Comprehension of the individual pharmacology, pharmacodynamics, and pharmacokinetics, in addition to the impact of concomitant immunomodulation on immunogenicity allows optimization of each biologic agent in the appropriate inductive or maintenance setting of IBD.


Assuntos
Anti-Inflamatórios/farmacologia , Produtos Biológicos/farmacologia , Fármacos Gastrointestinais/farmacologia , Doenças Inflamatórias Intestinais/terapia , Adalimumab , Anti-Inflamatórios/uso terapêutico , Anticorpos Monoclonais/farmacologia , Anticorpos Monoclonais Humanizados , Produtos Biológicos/uso terapêutico , Moléculas de Adesão Celular/antagonistas & inibidores , Certolizumab Pegol , Fármacos Gastrointestinais/uso terapêutico , Humanos , Fragmentos Fab das Imunoglobulinas , Doenças Inflamatórias Intestinais/patologia , Infliximab , Natalizumab , Polietilenoglicóis/farmacologia , Polietilenoglicóis/uso terapêutico , Fator de Necrose Tumoral alfa/antagonistas & inibidores , Fator de Necrose Tumoral alfa/metabolismo
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