Recent Advances in the Management of Refractory IBD

Recent Advances in the Management of Refractory IBD Raina Shivashankar, M.D. Assistant Professor of Medicine Division of Gastroenterology and Hepatology Thomas Jefferson University Philadelphia, PA

Outline Introduction Risk stratification Anti-TNFs Vedolizumab Ustekinumab Novel therapeutics Other anti-interleukin agents Tofacitinib (Janus Kinase inhibitor) Ozanimod (S1P1 modulator) Mongerson (anti-smad 7 oligonucleotide) Possible management algorithms

1. Colombel JF, et al. Gastroenterology 2017; 152: 351-361.

Goals of IBD Treatment Corticosteroid-free remission Mucosal healing Long term clinical remission (OR=2.8, 95% CI, 1.91-4.1) Avoidance of CD-related surgeries (OR=2.22, 95% CI, 0.86-5.69) Fewer hospitalizations Improve quality of life 1. Rutgeerts P, et al. Gut. 2007;56:453-5 2. Cintolo M, et al. World J Gastrointest Pathophysiol. 2016; 7: 1-16. 3. Sokol H, et al. Curr Opin Gastroenterol 2014; 30: 378-84. 4. Froslie K, et al. Gastroenterol. 2007. 133: 412-22.

Treat to Target Assess the following in 6 months after therapy initiation: - Clinical symptoms - Biomarkers (i.e. inflammatory markers, fecal calprotectin) - Endoscopic/mucosal healing is the goal 1. Colombel JF, et al. Gastroenterology 2017; 152: 351-361.

Why is my patient refractory to treatment? Infection CMV, C. diff Concomitant disease Celiac Medications Inadequate dosing of medications Antidrug antibody Strictures Cancer

Crohn s disease

Crohn s disease: Assess Inflammatory Status 1. Sandborn W, et al. Gastro. 2014;147(3):702-705

Crohn s disease: Risk stratification Treatment stratified based on severity and risk of complications 1. Sandborn W, et al. Gastro. 2014;147(3):702-705

Crohn s disease: Treatment based on risk stratification 1. Sandborn W, et al. Gastro. 2014;147(3):702-705

Anti-TNFs as Induction Therapy for Crohn s Disease Clinical remission Mucosal Healing Infliximab 33-72% 29% Adalimumab 21-43% 27% Anti-TNF naive 36-43% Anti-TNF exposed 21-26% Certolizumab 22-29.2% 10% Anti-TNF naive 22-26.4% Anti-TNF exposed 29.2% 1. Colombel JF, et al. N Engl J Med 2010;362:1383-95. 2. Lemann M, et al. Gastroenterology 2006;130:1054-61. 3. Targan SR, et al. N Engl J Med 1997;337:1029-35 4. Hanauer SB, et al. Gastroenterology 2006;130:323-33; quiz 591 5. Sandborn WJ, et al. Ann Intern Med 2007;146:829-38. 6. Watanabe M, et al. J Crohns Colitis 2012;6:160-73. 7. Sandborn WJ, et al. Clin Gastroenterol Hepatol 2010;8:688-695 e2. 8. Sandborn WJ, et al. N Engl J Med 2007;357:228-38. 9. Schreiber S, et al. Gastroenterology 2005;129:807-18.

Anti-TNFs as Maintenance Therapy (week 30-56) for Crohn s Disease Clinical remission Mucosal Healing Infliximab 42-49% 30% (mono)-44% (combo) Adalimumab 38-81% 24% Certolizumab 48% 14% 1. Colombel JF, et al. N Engl J Med 2010;362:1383-95. 2. Rutgeerts P, et al. Gastroenterology 2012;142:1102-1111 e2. 3. Hebuterne X, et al. Gut 2013;62:201-8.

A brief word on therapeutic drug monitoring (TDM) First biologic is the best chance at treating IBD Optimize medications with therapeutic drug monitoring Benefit: Increased duration of therapy with TDM 1. Vaughn B, et al. Inflamm Bowel Dis. 2014;20(11):1996-2003

1. Khanna R, et al. Aliment Pharmacol Ther. 2013;38:447-459

1. Khanna R, et al. Aliment Pharmacol Ther. 2013;38:447-459

Selected Targets in IBD Therapy TNFα-inhibitors block systemic inflammation a central cytokine leading to multiple downstream events 1,2 Vedolizumab blocks migration of leukocytes into the gut via α4β7 integrins 1 1. Danese S et al. Nat Rev Gastroenterol Hepatol. 2015;12:537-45 2. Tracey D et al. Pharmacol Ther 2008;117:244-79 3. Adapted from slide courtesy of Dr. Edward V. Loftus, Jr.

Vedolizumab in Moderate-Severe CD (GEMINI II) Induction Trial: Week 6 Endpoints Maintenance Trial: Week 52 Endpoints 1. Sandborn WJ et al. N Engl J Med. 2013; 369(8): 711-721

GEMINI II: Week 52 Outcomes Stratified by Anti-TNF Exposure 70 60 50 VDZ/PBO VDZ Q8W VDZ Q4W 51.5 46.5 60.6 53.5 Percent 40 30 38.6 29.5 30.7 26.8 23.2 26.8 38 20 17.1 10 0 Clinical CDAI-100 Remission Response Anti-TNF Exposed 1. Sandborn WJ et al. N Engl J Med. 2013; 369(8): 711-721 2. Adapted from slide courtesy of Dr. Edward V. Loftus, Jr. Clinical CDAI-100 Remission Response Anti-TNF Naïve

Real World Effectiveness of VDZ in Crohn s disease: VICTORY Consortium Retrospective cohort study of 7 US medical centers Majority (90%) previously exposed to anti-tnfs Cumulative remission rates 18% at 6 months 35% at 12 months 54% at 18 months Less likely to achieve clinical remission: Severe disease Active perianal disease Previous/active smoking Previous anti-tnf use Majority of clinical response seen after 6 months of treatment 1. Dulai PS, et al. Am J Gastroenterol. 2016; 111: 1147-1155.

Selected Targets in IBD Therapy TNFα-inhibitors block systemic inflammation a central cytokine leading to multiple downstream events 1,2 Ustekinumab blocks inflammation produced through IL12/23 1 Vedolizumab blocks migration of leukocytes into the gut via α4β7 integrins 1 1. Danese S et al. Nat Rev Gastroenterol Hepatol. 2015;12:537-45 2. Tracey D et al. Pharmacol Ther 2008;117:244-79 3. Adapted from slide courtesy of Dr. Edward V. Loftus, Jr.

1. Feagan BG and Sandborn WJ, et al. NEJM 2016; 375: 1946-60. UNITI Trials: Efficacy of Ustekinumab in Crohn s Disease 100 point reduction in CDAI

UNITI-IM: Ustekinumab Maintenance Trial in CD 1. Feagan BG and Sandborn WJ, et al. NEJM 2016; 375: 1946-60.

Other therapeutic targets Anti-IL23: MEDI2070 (brazikumab) and risankizumab bind p19 subunit JAK inibitors: - JAK-1 and -3 inhibitor: Tofacitinib - Selective JAK-1 inihibition: Filgotinib and Upadacitinib 1. Danese S et al. Nat Rev Gastroenterol Hepatol. 2015;12:537-45 2. Tracey D et al. Pharmacol Ther 2008;117:244-79

Subjects (%) Upadacitinib (ABT-494), a Selective Jak-1 Inhibitor Safe and Effective in Induction of Remission of Crohn s Disease Selective JAK-1 inhibitor Methods Phase II study Inclusion CDAI 240-450 (moderate-severe) Stool frequency 2.5 daily Abdominal pain 2 SES-CD 6 ( 4 for ileal only disease) 16 week induction Clinical remission (week 16) Stool frequency 1.5 Abdominal pain 1 80 60 40 20 0 N= Placebo 37 Endoscopic Remission at Week 12/16 3 mg 6 mg 12 mg 24 mg 24 mg 39 37 36 36 35 BID BID BID BID QD *P<0.1; **P<0.05; ***P<0.01 Sandborn WJ, et al. Presented at DDW. May 2017. Abstract 847h. Slide from Cornerstones 2017 Subjects (%) Methods Endoscopic remission (Week 12 and 16) SES-CD 4 and 2 point decrease Results 220 randomized patients Significant endoscopic remission at doses: 3-, 12- and 24 mg BID Significant clinical remission at 6 mg BID AE with JAK inhibitors: 1 case VZV, 2 GI perforation, 2 cardiovascular events, 1 NMSC 80 60 40 20 0 N= Placebo 37 Clinical Remission at Week 16 3 mg 6 mg 12 mg 24 mg 24 mg 39 37 36 36 35 BID BID BID BID QD

Filgotinib for Induction of Remission of Moderate-Severe Crohn s Disease FITZROY study (n=174) Filgotinib: once daily oral JAK1 inhibitor Primary endpoint CDAI < 150 at 10 weeks Serious AEs: 9% vs. 4% 200 mg filgotinib v. placebo for 10 weeks Serious infections: 3% vs. 0% Remission Response P-value Filgotinib 47% 59% P=0.0067 Placebo 23% 41% P=0.0386 Vermeire S, et al. DDW Late-Breaker May 2016. Abstract 812c. Vermeire S, et al. Lancet 2017;389(10066):266-75.

Targeting Smad7 With Mongersen (GED-0301) Mongersen (GED-0301) is an oral anti-sense oligonucleotide that inhibits Smad7 translation by facilitating degradation of the RNA Smad7 production is inhibited and the TGF-β1 R1 is freed Downstream signal is re-established Suppression of inflammatory gene expression is restored 26 Monteleone G, et al. N Engl J Med. 2015;372:1104-1113. Adapted from slide courtesy of Dr. Edward V. Loftus, Jr.

Mongersen in Steroid-Dependent or -Resistant Crohn s Disease Monteleone G et al. N Engl J Med. 2015;372:1104-1113.

Ulcerative Colitis

Ulcerative colitis Risk stratification Anti-TNFs Anti-integrin: Vedolizumab JAK inhibitor: Tofacitinib S1P1 modulator: Ozanimod

Ulcerative colitis: Risk Stratification Treatment stratified based on severity and risk of complications 1. Dassapoulos T, et al. Gastroenterol. 2015. 149: 238-245.

Ulcerative colitis: Risk stratification 1. Dassapoulos T, et al. Gastroenterol. 2015. 149: 238-245.

Anti-TNFs as Induction Therapy for Ulcerative Colitis Clinical remission Mucosal Healing Infliximab 33.9-38.8% 60.3-62% Adalimumab 18.5% 41.1-46.9% Certolizumab 17.9% 45.1% Rutgeerts P, et al. N Engl J Med 2005; 353: 2462-76. Danese S, et al. AP&T 2013; 37(9): 855-66. Lowenberg M et al. Clin Exp Gastroenterol. 2014;7:53-59

Anti-TNFs as Maintenance Therapy (week 30-54) for Ulcerative Colitis Clinical remission Mucosal Healing Infliximab 25.6-34.7% 45.5-50.4% Adalimumab 17.3% 25% Golimumab 27.8% 42.4% Rutgeerts P, et al. N Engl J Med 2005; 353: 2462-76. Danese S, et al. AP&T 2013; 37(9): 855-66. Lowenberg M et al. Clin Exp Gastroenterol. 2014;7:53-59

GEMINI I: EFFICACY OF VEDOLIZUMAB IN MODERATE-SEVERE UC Feagan BG et al, N Engl J Med. 2013;369:699-710

GEMINI 1: VDZ Efficacy Stratified by Anti-TNF Exposure Patients (%) 45 40 35 30 25 20 15 10 5 0 20.6 39 Clinical response Prior Anti-TNF Failure 3.2 Placebo (N=63) Vedolizumab (N=82) 9.8 Clinical remission Week 6 60 50 40 30 20 10 0 26.3 53.1 Clinical response Anti-TNF Naive 6.6 Placebo (N=76) Vedolizumab (N=130) 23.1 Clinical remission Feagan BG et al, N Engl J Med. 2013;369:699-710 Adapted from a slide courtesy of Dr. Edward V. Loftus, Jr.

GEMINI I: Vedolizumab Maintenance in UC 60 50 40 30 20 15.9 44.8 41.8 19.8 51.6 56 13.9 31.4 45.2 Placebo Vedo Q8wks Vedo Q4wks 10 0 Clinical Remission Mucosal Healing Steroid-Free Remission Feagan BG et al, N Engl J Med. 2013;369:699-710 Adapted from a slide courtesy of Dr. Edward V. Loftus, Jr.

Maintenance therapy with Oral Tofacitinib Causes Clinical Remission in Patients with UC 1. Sandborn WJ, et al. N Engl J Med. 2017. 376: 1723-36.

Maintenance therapy with Oral Tofacitinib Causes Endoscopic Remission in Patients with UC 1. Sandborn WJ, et al. N Engl J Med. 2017. 376: 1723-36.

Safety of Tofacitinib as UC Maintenance Therapy Adverse events, serious adverse events, serious infection rates similar in all treatment arms Overall infections higher, but withdrawal due to AE was lower Zoster signal at 10 BID dose No deaths No intestinal perforations Expected changes in lipids, CK PBO BID Tofa 5 mg BID Tofa 10 mg BID AEs % 75.3 72.2 79.6 SAEs 6.6 5.1 5.6 Any Infections 24.2 35.9 39.8 Serious 1.0 1.0 0.5 infections Herpes zoster 0.5 1.5 5.1 Malignancy 0.5 0 0 exc NMSC NMSC 0.5 0 1.5 Withdrawal due to AE 18.7 9.1 9.7 Sandborn WJ et al, ECCO 2017 Oral Presentation (OP032) and DDW 2017 Oral Presentation 1080; Sandborn WJ, et al. N Engl J Med. 2017. 376: 1723-36. Slide courtesy of Dr. Edward V. Loftus, Jr.

Sphingosine-1-phosphate Receptor (S1P1) Modulator: Ozanimod Involved in regulating many immunologic and CV effects Plays a role in lymphocyte trafficking from lymphoid organs S1P1-receptor agonists cause internalization and degradation of S1P1 receptor B and T cells unable to migrate from secondary lymphoid organs Reversible reduction in circulating lymphocytes 1. Sandborn WJ, et al. N Engl J Med. 2016. 374: 1754-62.

Ozanimod for Induction of Remission (Week 8) in Moderate-Severe UC Phase 2 RCT with oral S1P1 modulator N=197 Ozanimod 1mg v. placebo led to slightly higher rates of CR at week 8 (16% v. 6%, p=0.048) AEs comparable between groups 1. Sandborn WJ, et al. N Engl J Med. 2016. 374: 1754-62.

Potential Management Algorithm Moderate-Severe Crohn s Disease Anti-TNFs Optimize therapy Vedolizumab Ustekinumab Clinical trials Anti-IL 23 (Brazikumab, Risankizumab) JAK inhibitors (Upadacitinib, Filgotinib) Anti-SMAD 7 (Mongersen)

Potential Management Algorithm Moderate-Severe Ulcerative Colitis Anti-TNFs Optimize therapy Surgery Vedolizumab Optimize therapy Tofacitinib Clinical trials S1P1 modulator (ozanimod)

Conclusion Remember other causes of ongoing symptoms Optimize first therapy Treat to Target Therapeutic Drug Monitoring Vedolizumab can be considered first-line in UC Ustekinumab can be used in Crohn s disease Many medications are in development Other anti-il-23 agents Tofacitinib (JAK inhibitors) Ozanimod (S1P1 modulator) Mongerson (SMAD 7 antisense)

Thank you raina.shivashankar@jefferson.edu