Azathioprine for Induction and Maintenance of Remission in Crohn s Disease

Azathioprine for Induction and Maintenance of Remission in Crohn s Disease William J. Sandborn, MD Chief, Division of Gastroenterology Director, UCSD IBD Center

Objectives Azathioprine as induction and maintenance therapy for CD and UC Results of AZTEC and GETAID trials To review the evidence for use of combination therapy with an immumosuppressive and an anti-tnf biologic in patients with IBD To review the evidence regarding adverse effects associated with azathioprine

NCCDS: Cumulative Remission During Therapy With Azathioprine for Active Crohn s Disease 70 60 Azathioprine 2.5 mg/kg (250 mg) Placebo Patients (%) 50 40 30 20 10 0 0 5 10 15 Weeks After Randomization NCCDS = National Cooperative Crohn s Disease Study. Summers. Gastroenterology. 1979

AZA/6-MP versus Placebo or Control Induction of Clinical Remission Chande 2014a

Efficacy of Azathioprine as Maintenance Therapy in Adults With Refractory Crohn s Disease % of Patients Still in Remission 100 80 60 40 20 0 Placebo (N=30) AZA 2.5 mg/kg per day (N=33) 42% P=.001 7% 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Duration of Trial (months) * Remission induced by prednisolone tapered over 12 wk Reproduced with permission from Candy S et al. Gut. 1995;37:674.

6-Mercaptopurine for Maintenance of Remission in Moderate-to-Severe Pediatric Crohn s Disease % of Patients in Remission 100 N=55 90 80 70 60 50 40 30 6-MP Control 0 50 100 150 200 250 300 350 400 450 500 550 600 Days Since Remission Induction 91% P<.007 53% At baseline, patients received prednisone plus either 6-MP or placebo. Steroids were tapered after induction of remission. Markowitz J et al. Gastroenterology. 2000;119:895

Top Down Therapy With Azathioprine + Prednisone versus Prednisone in Adults with Newly Diagnosed Crohn s Disease Sustained steroid free remission Survival free of relapse Panes J. Gastroenterology 2013

Top Down Therapy With Azathioprine + Prednisone versus Step Up Therapy with Prednisone and then Azathioprine in Adults with Newly Diagnosed Crohn s Disease Cosnes J. Gastroenterology 2013

AZA/6-MP versus Placebo Outcome = Maintenance of Clinical Remission Chande 2014b

Rate of Surgery for Crohn s Disease and the Use of Immunosuppressives in Paris Over 3 Decades Probability of Receiving Immunosuppressives 60 50 40 30 20 10 0 Use of Immunosuppressives # Resections per 100 Patients 25 20 15 10 1978 2002 1979 2002 5 0 Need for Surgery Cosnes J, et al. Gut. 2005:54:237-241.

6-Mercaptopurine and Mesalamine for Prevention of Post-Operative Recurrence of Crohn s Disease 6-Mercaplopurine Mesalamine Placebo Clinical Relapse-Free Survival 1.00 0.75 0.50 0.25 0.00 0 200 400 600 800 Days Since Baseline Visit Endoscopic Relapse-Free Survival 1.00 0.75 0.50 0.25 0.00 0 200 400 600 800 Days Since Baseline Visit Hanauer S et al. Gastroenterology. 2004;127:723.

Estimate of Efficacy of AZA for Treatment Success in UC Patients: Meta-Analysis Pooled RR Estimate Across 5 Trials Study Risk ratio (95% CI) % Weight Ardizzone 2006 Sood 2002 Sood 2003 Sood 2000 Jewell 1974 Overall (95% CI) 2.71 (1.30, 5.65) 17.3 1.72 (0.96, 3.07) 21.4 0.68 ( 0.31, 1.50) 15.9 1.06 (0.71, 1.58) 27.0 1.78 (0.89, 3.54) 18.4 1.42 (0.93, 2.17).176982 1 5.65028 Risk ratio Leung Y et al. Dig Dis Sci. 2008;53:1455

What is the Evidence for Use of Combination Therapy with an Immumosuppressive and an Anti- TNF Biologic in Patients with IBD? Combination therapy More effective in prospective randomized trials Reduces rates of antibody formation Results in higher blood concentrations of the biologic Similar side effect profile to monotherapy

SONIC: Clinical Remission without Corticosteroids at Week 26 Proportion of Patients (%) 100 80 60 40 20 0 Primary End Point P<0.001 P=0.006 P=0.022 57 44 30 51/170 75/169 96/169 AZA + placebo IFX + placebo IFX + AZA IFX, infliximab Colombel JF, et al. Infliximab, azathioprine, or combination therapy for Crohn's disease. N Engl J Med. 2010 Apr 15;362(15):1383-1395. 2010 Massachusetts Medical Society. All rights reserved.

SONIC: Mucosal Healing at Week 26 Proportion of Patients (%) 100 80 60 40 20 0 P<0.001 P=0.023 P=0.055 44 30 17 18/109 28/93 47/107 AZA + placebo IFX + placebo IFX + AZA Colombel JF, et al. Infliximab, azathioprine, or combination therapy for Crohn's disease. N Engl J Med. 2010 Apr 15;362(15):1383-1395. 2010 Massachusetts Medical Society. All rights reserved.

Infliximab, Azathioprine, or Infliximab + Azathioprine for Treatment of Moderate to Severe UC: UC SUCCESS Trial Primary End Point: Steroid-Free Remission at Week 16 100 P=0.017 AZA IFX IFX + AZA 80 P=0.032 Patients (%) 60 40 20 24% P=0.813 22% 40% 0 18/76 17/77 31/78 UC, ulcerative colitis Panaccione R et al. Gastroenterology 2014

Infliximab, Azathioprine, or Infliximab + Azathioprine for Treatment of Moderate to Severe UC: UC SUCCESS Trial Major Secondary End Point: Response at Week 16 100 P=0.001 P=0.514 AZA IFX IFX + AZA 80 P=0.018 69% 77% Patients (%) 60 40 50% 20 0 38/76 53/77 60/78 Panaccione R et al. Gastroenterology 2014.

Infliximab, Azathioprine, or Infliximab + Azathioprine for Treatment of Moderate to Severe UC: UC SUCCESS Trial Secondary End Point: Mucosal Healing at Week 16 100 P=0.001 P=0.295 AZA IFX IFX + AZA 80 P=0.028 Patients (%) 60 40 n=28 37% 55% 63% 20 0 28/76 42/77 49/78 Panaccione R et al. Gastroenterology 2014

SONIC: Immunogenicity Results at Week 30* Positive Negative Inconclusive 100 98 94 Patients (%) 80 60 40 20 0 1/89 1 14 15 0/89 1/120 2/120 87/89 0 1 2 15/106 16/106 72/106 113/120 AZA + placebo IFX + placebo AZA + IFX 68 *Patients who had 1 or more PK samples obtained after their first study agent administration were included in the analysis. PK data at Wk 30 was not available for 1 patient treated with AZA + placebo, 3 patients treated with IFX + placebo, and 4 patients treated with AZA + IFX. Colombel JF et al. N Engl J Med. 2010;362:1383. Sandborn WJ. Unpublished data.

ACCENT 1 IFX in Crohn s Disease: Median Serum IFX Trough Concentrations Over Time Stratified by Immunosuppressive Therapy Median Infliximab Concentration (µg/ml) 100 10 1 0.1 ACCENT 1 5 mg/kg Infliximab Maintenance 0 2 6 14 22 30 38 46 54 IMM, n= 51 50 49 48 42 36 32 29 27 No IMM, n= 136137 132 120 99 82 70 59 53 Weeks IMM No IMM IMM, immunomodulator Lichtenstein GR, et al. Clinical trial: benefits and risks of immunomodulators and maintenance infliximab for IBD-subgroup analyses across four randomized trials. Aliment Pharmacol Ther. 2009 Aug;30(3):210-226. With permission from John Wiley and Sons.

ACCENT 1 IFX in Crohn s Disease: Serum IFX Trough Concentration at the Last Clinical Visit Stratified by Immunosuppressive Therapy Infliximab Concentration (µg/ml) 100 10 1 0.1 ACCENT 1 IMM No IMM 0.01 n= 27 53 23 55 5 mg/kg infliximab 10 mg/kg infliximab IMM, immunomodulator Lichtenstein GR, et al. Clinical trial: benefits and risks of immunomodulators and maintenance infliximab for IBD-subgroup analyses across four randomized trials. Aliment Pharmacol Ther. 2009 Aug;30(3):210-226. With permission from John Wiley and Sons.

SONIC: IFX Trough Levels at Week 30* 10 Median Serum Trough Levels (µg/ml) 8 6 4 2 0 1.6 (n=97) 3.5 (n=109) IFX + placebo IFX + AZA *Patients who had 1 or more PK samples obtained after their first study agent administration were included in the analysis Colombel JF, et al. Infliximab, azathioprine, or combination therapy for Crohn's disease. N Engl J Med. 2010 Apr 15;362(15):1383-1395. 2010 Massachusetts Medical Society. All rights reserved.

Adverse Events with Azathioprine

Toxicity of Azathioprine and 6-Mercaptopurine in Inflammatory Bowel Disease Overall toxicity 15% Pancreatitis 3.3% Bone marrow 2% depression Allergic reactions 2% Drug hepatitis 0.3% Infectious 7.4% complications Malignant neoplasm 3.1% Lymphoma Meta-analysis of 6 studies showed that AZA/6MP treatment is associated with 4-fold increase (SIR = 4.2 [95% CI = 2.1 7.5]) in risk of EBV-positive lymphoma Connell Kinlen Farrell Lewis Fraser Korelitz Summary Lymphoma 0 10 Present DH et al Ann Int Med. 1989;111:641 Kandiel A et al. Gut. 2005:54;1121

CESAME: Incidence rates of lymphoproliferative disorders according to azathioprine exposure grouped by age at entry in the cohort Beaugerie L. Lancet 2009

Risk of NH Lymphoma with anti-tnf + IM treatment for Crohn s Disease Meta-analysis Results 8905 patients representing 20,602 pt-years of exposure 13 Non-Hodgkin s lymphomas Mean age 52, 62% male 10/13 exposed to IM* (really a study of combo Rx) 6.1 per 10,000 pt-years NHL rate per 10,000 SIR 95% CI SEER all ages 1.9 - - IM alone 3.6 - - Anti-TNF + IM vs SEER 6.1 3.23 1.5-6.9 Anti-TNF+ IM vs IM alone 6.1 1.7 0.5-7.1 *not reported in 2 Siegel et al, CGH 2009;7:874

Risk of Skin Cancer Associated with Thiopurines (CESAME) 19,486 IBD patients 32 cases of skin cancer (20 basal cell, 12 squamous) Look at denominator Peyrin-Biroulet L, et al. Gastroenterology 2011

SONIC: Summary of Adverse Events Through Week 50 All Randomized Patients AZA + placebo (n=161) IFX + placebo (n=163) IFX + AZA (n=179) Pts with 1 AE, n (%) 144 (89.4%) 145 (89.0%) 161 (89.9%) Pts with 1 SAE, n (%) 43 (26.7%) 39 (23.9%) 27 (15.1%) Serious infections 9 (5.6%) 8 (4.9%) 7 (3.9%) Tuberculosis: 1 patient treated with infliximab and azathioprine Colon cancer: 2 patients treated with azathioprine monotherapy Death: postcolectomy, in a patient treated with azathioprine monotherapy Colombel JF, et al. Infliximab, azathioprine, or combination therapy for Crohn's disease. N Engl J Med. 2010 Apr 15;362(15):1383-1395. 2010 Massachusetts Medical Society. All rights reserved.

Conclusions Azathioprine monotherapy is not effective for induction, it may be modestly effective for maintenance of steroid induced remission in patients with established Crohn s disease Combination therapy is more effective than azathioprine or anti-tnf monotherapy for steroid-free remission and mucosal healing Combination therapy results in lower immunogenicity and higher anti-tnf antibody blood concentrations Monotherapy and combination therapy have similar rates of serious infection when considering the combined rates of BOTH disease related infections and opportunistic infections

Conclusions Azathioprine monotherapy is not effective for induction, it may be modestly effective for maintenance of steroid induced remission in patients with established Crohn s disease Combination therapy is more effective than azathioprine or anti-tnf monotherapy for steroid-free remission and mucosal healing Combination therapy results in lower immunogenicity and higher anti-tnf antibody blood concentrations Monotherapy and combination therapy have similar rates of serious infection when considering the combined rates of BOTH disease related infections and opportunistic infections