I am grateful to have had the opportunity to attend Digestive Disease Week (DDW) 2021. Learning about diagnosing and managing pediatric IBD in the 21st century allowed me to reflect on my own experiences as a pediatric patient through a different perspective. Two presentations stood out to me in this session.
To begin with, the first presentation that stood out to me,“Therapeutic Drug Monitoring with Newer Biologics”, was led by Dr. Lissy de Ridder who highlighted ustekinumab, vedolizumab and infliximab treatments. Dr. Ridder emphasized “treating-to-target” pediatric patients because of the lack of treatment options for this patient population.
Dr. Ridder explained what Anti-TNF therapeutic drug monitoring (TDM) has taught us about secondary loss of response:
A secondary loss of response that is immunogenic is categorized by a decrease of the drug and an increase of antibodies in the patient.
A secondary loss of response that is pharmacokinetic is categorized as a decrease of the drug and no antibodies in the patient.
A secondary loss of response that is pharmacodynamic is categorized as a sufficient level of drug and no antibodies in the patient but the patient does not respond to the drug.
The course of action for these different types of secondary loss of response according to Dr. Ridder:
A patient who has an immunogenic secondary loss of response to a drug will have the drug exchanged for a new drug in the same class and an immunomodulator will be added to the treatment plan.
A patient who experiences a pharmacokinetic secondary loss of response to a drug will have the dose of the drug increased and/or decrease the intervals that the drug is received.
A patient who experiences a pharmacodynamic secondary loss of response requires that the drug be exchanged for a drug of a different class or surgery.
Additionally, Dr. Ridder and her team conducted a study analyzing trough levels of young pediatric patients using infliximab and found that 75% of these patients were underdosed at the beginning of their treatment. As a result, these patients also did not have the recommended trough level and therefore responded less to infliximab. These results reveal that young pediatric patients responded less to infliximab because of underdosing.
Because of Dr. Ridder and her team’s study, the Medical Management of Pediatric Crohn’s Disease ECCO-ESPGHAN Guideline has changed to:
“In patients on anti-TNF agents, early proactive therapeutic drug monitoring [TDM] followed by dose optimisation is recommended. LoE:2 Agreement: 87.5”
Other highlights of Dr. Ridder’s presentation were:
Vedolizumab is more successful in UC patients compared to CD patients and is used after failure to anti-TNF in patients
Vedolizumab should not be used in patients with acute severe colitis
Ustekinumab should be used for CD patients who experience failure to anti-TNF and also patients who have severe psoriasis
The second presentation that stood out to me, “Results of the First Pilot Randomized Controlled Trial of Faecal Microbiota Transplant for Pediatric Ulcerative Colitis” was led by Dr. Nikhil Pai who highlighted patient interest in FMT and the barriers to FMT.
Dr. Nikhil Pai stressed that this trial was a result of a “significant patient and parent interest and emerging FMT data”. The study compared patients who received FMT treatments vs. patients who received placebo treatments for six weeks. The patients involved in this study were “UC patients between the ages of four to seventeen, had active disease, no CDI and no significant change in Rx in four weeks”.
The study highlights:
Fecal calprotectin significantly decreased in FMT recipients compared to placebo group
FMT is beneficial six months after initial treatment
Future studies of FMT should consider at-home treatment or oral encapsulated therapies due to the lack of feasibility of the study
Supports FMT for pediatric UC patients
Need for more FMT research
Overall, I am excited to see future studies about new treatments for pediatric patients with IBD and how these treatments will transition into adulthood.