What is your goal when you use Adacolumn® in combination with Anti -TNF?

Dr. Daniel Ginard

When we are speaking on combination therapy between Anti-TNF and apheresis therapy, we first we are going to aim for the same as in other scenarios. We are aiming for clinical remission and improvement of the flare but we are also adding a different aim to this therapy because we usually are facing a refractory patient and we are trying to avoid a switch to another biological therapy, therefore changing from Anti-TNF to another biologic. And also, we are going to aim for reducing the dosing or the dose intensified Anti-TNF in some cases because we are using more drug to this patient with Anti-TNF plus the phases we can try to reduce and to come back to the standard dosing of the Anti-TNF so this is one of the benefits of reducing the inflammatory bowel and improving the context of the disease to try to recapture the response to the Anti-TNF.

References:

• Rodríguez-Lago I, Benítez JM, Sempere L, Sáez-González E, Barreiro-de Acosta M, de Zárate JO, Cabriada JL. The combination of granulocyte-monocyte apheresis and vedolizumab: A new treatment option for ulcerative colitis? J Clin Apher. 2019 Dec;34(6):680-685.
• Yoko Yokoyama, Koji Sawada, Nobuo Aoyama, et al:  Efficacy of Granulocyte and Monocyte Adsorptive Apheresis in Patients With Inflammatory Bowel Disease Showing Lost Response to Infliximab, Journal of Crohn’s and Colitis 2020,1-10.
• Bamias G, Zampeli E, Domènech E. Targeting neutrophils in inflammatory bowel disease: revisiting the role of adsorptive granulocyte and monocyte apheresis. Expert Rev Gastroenterol Hepatol. 2022 Aug;16(8):721-735.
• Domènech, E., et al Use of granulocyte/monocytapheresis in ulcerative colitis: A practical review from a European perspective. World journal of gastroenterology, 2021; 27(10), 908–918.

Dr. Eugeni Doménech

When we use GMA in combination with biological therapies, the endpoint should always be the same. So, it doesn’t matter if we are combining GMA with Anti-TNF, Vedolizumab or Ustekinumab. The main objective should be the achievement of clinical remission of the patient. The time for achieving this target may vary depending on the indication of combination therapy. So, if the patient is starting concomitantly biological therapy and GMA, we can wait for a shorter time that if you add on GMA to a patient that has a secondary loss of response or a partial response to biological therapies.

References:

• Yoko Yokoyama, Koji Sawada, Nobuo Aoyama,  et al:  Efficacy of Granulocyte and Monocyte Adsorptive Apheresis in Patients With Inflammatory Bowel Disease Showing Lost Response to Infliximab, Journal of Crohn’s and Colitis 2020,1-10.
• Rodríguez-Lago I, et al.: . Granulocyte-monocyte apheresis: an alternative combination therapy after Loss of response to anti-TNF agents in ulcerative colitis? Scand J Gastro 2019 Apr;54(4):459-464.

Dr. Iago Rodríguez Lago

Many new drugs have been included in the treatment strategy of the apheresis colitis patients and we now have available different biological therapies but also immunosuppressive therapies, especially JACK inhibitors like Tofacitinib. And this makes a different scenario than five or ten years ago for UC. And this means that many patients can benefit from these new therapies but we are probably facing similar problems than in previous years. And this means that these patients receiving new therapies that can benefit from Tofacitinib, Vedolizumab, Ustekinumab for the treatment of UC. But some of them, they are still also losing response to these therapies or demonstrating insufficient response to these therapies. And well the apheresis comes here again, and it has demonstrated at least with some cohort studies that it can be beneficial in terms of clinical response and also safety that it is very important in these combination therapies and also with biomarkers. So well, this is still an option with the immunosuppressive and biological therapies and combination therapy with a apheresis plus a biologic or immunosuppressive therapy is an option for our patients now.

References:

• Rodríguez-Lago I, Benítez JM, Sempere L, Sáez-González E, Barreiro-de Acosta M, de Zárate JO, Cabriada JL. The combination of granulocyte-monocyte apheresis and vedolizumab: A new treatment option for ulcerative colitis? J Clin Apher. 2019 Dec;34(6):680-685.
• Yoko Yokoyama, Koji Sawada, Nobuo Aoyama, et al:  Efficacy of Granulocyte and Monocyte Adsorptive Apheresis in Patients With Inflammatory Bowel Disease Showing Lost Response to Infliximab, Journal of Crohn’s and Colitis 2020,1-10.
• Bamias G, Zampeli E, Domènech E. Targeting neutrophils in inflammatory bowel disease: revisiting the role of adsorptive granulocyte and monocyte apheresis. Expert Rev Gastroenterol Hepatol. 2022 Aug;16(8):721-735.
• Domènech, E., et al Use of granulocyte/monocytapheresis in ulcerative colitis: A practical review from a European perspective. World journal of gastroenterology, 2021; 27(10), 908–918.

Dra. Pilar Nos

Combined treatment with Adacolumn and biologics, of which the one we have the most experience with is infliximab (anti-TNF) because it was the first biologic used in refractory ulcerative colitis, and the experience published is mainly from retrospective series with a limited number of patients. No prospective, randomised etc. clinical trials have been published but some prospective series have been. The therapeutic benefit is around 30%, they are very heterogeneous studies. I know that you can’t compare these series either because some are small series and it’s practically 100%, but let’s say that yes, I’d say that in a significant number of patients the benefits of the combination therapy could be around 30-40% in selected patient groups. We think that all these studies, as they are observational studies not clinical trials, that they have a patient selection bias that normally you’re already using it in this patient who you think is a candidate responder or in whom other lines have already failed, or who you think has an elevated toxicity. But I think there is a future for a combined anti-TNF and apheresis therapy.

References:

• Rodríguez-Lago I, Benítez JM, Sempere L, Sáez-González E, Barreiro-de Acosta M, de Zárate JO, Cabriada JL. The combination of granulocyte-monocyte apheresis and vedolizumab: A new treatment option for ulcerative colitis? J Clin Apher. 2019 Dec;34(6):680-685.
• Yoko Yokoyama, Koji Sawada, Nobuo Aoyama,  et al:  Efficacy of Granulocyte and Monocyte Adsorptive Apheresis in Patients With Inflammatory Bowel Disease Showing Lost Response to Infliximab, Journal of Crohn’s and Colitis 2020,1-10.
• Bamias G, Zampeli E, Domènech E. Targeting neutrophils in inflammatory bowel disease: revisiting the role of adsorptive granulocyte and monocyte apheresis. Expert Rev Gastroenterol Hepatol. 2022 Aug;16(8):721-735.
• Domènech, E., et al Use of granulocyte/monocytapheresis in ulcerative colitis: A practical review from a European perspective. World journal of gastroenterology, 2021; 27(10), 908–918.