P. S. KUNDHAL ET AL. JAMA November, 2013 Moderator – Dr Vineet Ahuja

1. Effect of Thalidomide on clinical remission in children and adolescents with refractory Crohn’s disease P. S. KUNDHAL ET AL. JAMA November, 2013 Moderator – Dr Vineet Ahuja

2. Introduction • 1.2 million people in Europe and more than half million in the United States are estimated to have Crohn’s disease • Prevalence is particularly high in North America and Europe (319 to 322 per 100000) • The highest annual incidence of CD was 12.7 per 100,000 person-years in Europe, 5.0 person-years in Asia and the Middle East, and 20.2 per 100,000 person-years in North America. Molodecky NA, Gastroenterology2012

3. 25% people of CD develop symptoms as children • Resistanceor intolerance to therapy is common in children • Approximately 18%of cases require surgery within 5 years from onset • If not adequately treated, children with Crohn disease may have permanent impairments

4. Thalidomide is a small molecule with anti TNF α, immunomodulatory, and antiangiogenicproperties • Observational studies on thalidomide have reported encouraging results, with remission rates ranging from 40% to 70% LaffitteE, Expert Opin Drug Saf,2004 Ginsburg PM,Ann Med,2001

5. Aim • To determine whether thalidomide is effective in inducing remission in refractory pediatriccrohn’s disease

6. Clinical activity was measured by the PediatricCrohn Disease Activity Index (PCDAI) • PCDAI score ranges from 0 to 95 • score >10 indicating active disease • Score ≥ 30 indicate moderate to severe disease • Score ≥ 15 required for inclusion

7. Resistance to immunosuppressants was defined as active disease despite • Prednisone, 2mg/kg per day (maximum 60 mg/d) or the equivalent for 8 weeks • Azathioprine or mercaptopurine for 4 months • Methotrexatefor 3 months • Infliximab5 mg/kg at 0, 2, and 6 weeks • Cyclosporine, oral 2 mg/kg per day for 4 weeks or intravenously 1 mg/kg per day for 1 week

8. Inclusion Criteria • Children and adolescents aged 2 to18 yrs • Active crohn’sdisease despite immunosuppresion • Adverse events preventing continuous treatment

9. Exclusion criteria • Requiring immediate surgery • Ongoing pregnancy • Neuropathy • HIV /Tumors • Transplanted organs • ongoing major infections • Participation in other experimental studies, • Infliximab in the previous 8 weeks

10. Study Design • Multicenter, Double-blind,placebo-controlled, RCT (Italy) • Randomised to thalidomide or placebo and followed for 8 weeks • In placebo group who at 8 weeks were not in clinical remission or did not have 75% response were given thalidomide • Followed up in an open-label extension for an additional 8 weeks to verify whether they responded to thalidomide after failure with placebo • After RCT phase, responders to thalidomide were followed up to additional 52 weeks to document long-term efficacy and adverse events related to thalidomide

11. Randomization and Masking • Randomization done by computer generated list • Both clinicians and children and their families were blinded for the randomized controlled trial phase (8 weeks) • Subsequently, the study continued open label

12. Study Treatment • Thalidomide given in dosage of 50,100,or 150 mg to patients weighing <30 kg, 30 to 60 kg, and >60kg,respectively • Immunosuppressant use was suspended except tapering steroids because of a relapse

13. Evaluation of Efficacy and Adverse Events • Done weeks 0, 4 and 8 Diary data General patient condition, Frequency and type of abdominal pain Stool characteristics Any other complaint .Laboratory samples Hematocrit Ferritin ESR CRP Albumin Electrolytes PCDAI and nutritional indicators were calculated, and adverse events were recorded

14. Adverse events • Evaluation conducted at each visit A detailed history Vital signs Physical examination Laboratory analysis

15. Peripheral neuropathy is a possible adverse event related to use of Thalidomide • Electromyography (EMG) was performed at weeks 8 to 12 for all patients • With peripheral neuropathy had to cease receiving thalidomide

16. Primary End Points • Clinical remission at week 8, defined by a PCDAI score of 10 or less • Reduction in PCDAI score of ≥ 25% or ≥ 75%, measured at weeks 4 and 8

17. Secondary End Points • Mean PCDAI score • CRP level • ESR • BMI • Weight for age • Physician Global Assessment score • Incidence of adverse effects

18. Longer-term Follow-up • Responders to thalidomide were followed prospectively for a minimum of 52 weeks • Outcomes were evaluated at 12, 16, 26, and 52 weeks and every 26 weeks thereafter • Primary efficacy outcomes were clinical remission and clinical response 75% • Secondary outcomes included mean time to reach remission, mean PCDAI score, steroid suspension, and thalidomide dose • Adverse events were monitored at each visit, and EMGs were repeated every 3 months during the follow-up

19. Statistical Analysis • Results from the group randomized to thalidomide were compared with those of the group who later began receiving thalidomide, with statistical tests for unpaired data, • Results from the group who later began receiving thalidomide were compared with those from the placebo group, using tests for paired data.

20. Multivariable logistic regression analysis used to evaluate if baseline characteristics were associated with the primary outcome (clinical remission) • Maintenance of clinical remission over time analyzed by using Kaplan-Meier curves, and the log- rank test was used to compare differences between them. • Adverse events were reported as incidence for the randomized controlled trial phase and as cumulative incidence (number of events/patient-weeks) for the long-term follow-up

21. Flow chart of patient in trial

22. Baseline characteristics were similar among groups, except for the mean ESR value, which was higher in patients randomized to thalidomide

23. Baseline charcterstics

24. Baseline characterstics

25. Results • Primary End Point • At week 8, 13 of 28 children receiving thalidomide (46.4%) compared with 3 of 26 of those receiving placebo (11.5%) reached clinical remission (P<.01)

26. At 4 weeks 25% and 75% responses were not different between groups • At week 8, Thalidomide group had a better response 25% response - 64.2% vs 30.8% 75% response - 46.4% vs 11.5% ( P <.01 for both)

27. PCDAI scores of groups by time

28. Secondary end points • At week 8, Mean PCDAI score, ESR, weight for age, and physician global assessment scores were all significantly improved in the thalidomide group compared with the placebo group • By week 4 Thalidomide had induced a significant decrease in ESR and decreased the number of children with undernutritionwhen measured with weight- for-age z score less than−1SD,but there were no other significant differences in the secondary outcomes between treatment groups.

29. Efficacy Data

30. Efficacy Data

31. Independent predictors of treatment failure • Previous therapy with infliximab • PCDAI score >30 • Weight-for-age z score <−1 SD • EIM

32. In the open label extension,of the 23 non responders to placebo, 2 needed surgery, whereas 21 given thalidomide • 11 of 21 (52.4%) reached clinical remission at week 8 (P<.01). • Results of other outcomes comparing those crossed over to begin receiving thalidomide with the placebo group were similar to the outcomes of the randomized controlled trial

33. Longer-term Follow-up • Over all remission rate with thalidomide was 63.3% (31/49) • Overall, 32 children (65.3%) achieved 75% response • Mean time to reach remission was 10.1 weeks • Mean duration of clinical remission in thalidomide group was 181.1 weeks v/s 6.3 weeks in the placebo group (P<.001) • No differences in the duration of remission in originally randomized to thalidomide and who began receiving it after failure of placebo (P = .90) • All the children had ceased receiving steroids by week 16 • Thalidomide daily dose was progressively decreased during follow-up without losing clinical efficacy

34. Adverse Events • Nine severe adverse events requiring treatment suspension occurred, for a cumulative incidence of 2.1 per 1000 patient-weeks • Peripheral neuropathy was the most frequent severe adverse event. • Clinical neuropathy was observed with a minimum cumulative dose of 380 mg/kg (equivalent to 10 months of thalidomide therapy). • Most patients reached very high cumulative doses of thalidomide without developing clinical neuropathy

35. Other severe adverse events observed were amenorrhea, bradycardia, and 1 case of an acute neurologic event, interpreted as possible migraine or transient ischemic attack • Overall, non serious adverse events had a total cumulative incidence of 12.2 cases per 1000 patient-weeks

36. Adverse effects

37. Discussion • Children with refractory crohn’sdisease account for about 30% of pediatriccrohn’sdisease cases and represent a subgroup with a higher risk of permanent impairment and higher health care costs for the individual and society • New effective and safe drugs are needed for these children.

38. Thalidomide was effective even in children with previous failure or intolerance to infliximab. • All these molecules have an antitumor necrosis factor α effect • Thalidomide also has an independent antiangiogeneticeffect on vascular endothelial growth factor and basic fibroblastic growth factor, both of which are highly expressed in Crohn disease.

39. The poor response to placebo (11.5%) confirms that sample represents cases of aggressive Crohn disease

40. Overall,this study suggests that safety of thalidomide in children with Crohn disease may be acceptable compared with that of other drugs. However, the study was clearly under powered to detect rare adverse events

41. Conclusions • Among children and adolescents with refractory Crohndisease, the use of thalidomide compared with placebo resulted in improved clinical remission at 8 weeks of treatment and longer term maintenance of remission in an open label follow- up. • These findings require replication to definitively determine the utility of this treatment

42. PCDAI • Abdominal pain • Stools • Patient functioning, general well-being (Recall, 1 week) • Weight • Height • Abdomen • Peri-rectal disease • Hct(%) • ESR (mm/hr) • Albumin (g/L) Adult CDAI • Abdominal pain • Stools • Patient functioning, general well-being (Recall, 1 week) • Weight • Abdomen mass • Extra-intestinal manifestations • Hct(%) • Antidiarrhoeals

43. Effect of magnesium supplementation and depletion on the onset and course of acute experimental pancreatitis Schick V, et al. Gut 2013

44. Introduction • Acute pancreatitis, a fatal disease for 20% of severely affected patients • Premature and intracellular activation of digestive proteases induces tissue injury • Elevated concentrations of acinarcytosolic calcium are an important trigger of the disease Ward JB, Lancet,1995

45. Under experimental conditions the removal of calcium from the incubation media or chelation of intracellular calcium prevents cellular injury Mooren F,J BiolChem2003 • On secretagoguestimulation, intracellular protease activation is primarily observed at the apical pole of acinar cells at the site where the stimulus-induced calcium release takes place Kruger B, Am J Pathol2000

46. Magnesium deficiency has been reported in individuals with chronic pancreatitis. PapazachariouIM, ClinChimActa2000 • Increased intracellular magnesium concentrations directly influence the frequency and amplitude of calcium oscillations in response to cholecystokinin (CCK) or the acetylcholine analogue carbachol. Mooren ,FASEB J, 2001

47. Aim • To investigate the effect of magnesium on premature enzyme activation in vitro as well as on pancreatic inflammation in vivo

48. MATERIALS AND METHODS

49. Cell isolation procedure • Pancreatic acini were prepared • After a 12-h fast animals were killed • Pancreas was rapidly removed • Pancreas minced into small pieces and placed into buffer

50. Measurment of intracellular calcium was done • Protease activity (intracellular trypsin and elastase activity) was measured in isolated acini • ATPase activity and kinase activity was measured in isolated acini