Use of anti-inflammatory biologics agents after intestine transplantation - a multicenter survey

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Conference Proceeding

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Introduction: Intestinal transplantation (IT) is a therapeutic option for patients with intestinal failure. A barrier to the success of IT is the significant risk of rejection and possible for disease recurrence in the patient's graft. A potential option for treating rejection refractory to mainstays of treatment and for managing disease recurrence are anti-inflammatory biologic agents. This survey was conducted to describe the utilization of these agents in IT centers in the United States Methods: A survey was conducted with questions pertaining to the utilization of biologics in IT in regard to agents used, dosing, infectious prophylaxis, duration, indication, outcomes, adverse effects, and barriers to use. The survey was distributed among centers in the United States via email database. Results: A total of 6 centers responded to the survey. Three centers treated adult population only; two pediatric and one both. The most utilized biologic was infliximab, then vedolizumab, and then some minimal usage of ustekinumab and adalimumab. For indications, most biologics were being used for refractory rejection and some minimal usage for Crohn's disease recurrence and nonspecific ulceration. Infectious prophylaxis use varied among the reported centers: 2 centers did not utilize prophylaxis, 2 used prophylaxis for bacterial, mold and fungal organisms, 1 specifically Pneumocystis jiroveci, and 2 others focused on Pneumocystis jiroveci and Cytomegalovirus. Most centers administered agents anywhere between 1-18 months and 4-6 doses. A center reported over 36 months in the case of 1 patient for inflammatory bowel disease. Only 1 center reported utilizing tumor necrosis factor (TNF) alpha levels to assist with dosing. Outcomes of reported biopsy results were predominantly some improvement and a reported 50% incidence of graft loss due to inefficacy. Lastly, biologics were well tolerated with 1 report of infusion reactions and infections being the more common adverse event. The only barriers reported to initiating therapy was the need for prior authorizations by 3 centers. Conclusion: This survey provided insight into the practice of using anti-inflammatory biologics in intestinal transplantation. Their utilization appears to have some consistencies as far as agents used and indications for utilization. However, practices differ when it comes to infectious prophylaxis and TNF- alpha levels. As with most novel therapies, insurance approval can lead to barriers with use. Biologics have been proven to be useful agents for specific indications after IT but more guidance and data are needed to streamline utilization and provide data to support use for insurance approval.

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