Introduction

Knowledge on the long-term disease course of microscopic colitis (MC) is unknown, and rests on retrospective studies. No predictive markers of disease course and disease activity have been identified. This 5-year prospective follow-up of a European incidence cohort aims to address these questions.

Aims & Methods

Incident cases of MC were prospectively included at 14 European centres. Patient characteristics and data on histology, disease activity, medical history, quality of life and treatment were registered. Patients were followed prospectively at 3, 6, 12 months and annually up to 5 years.

Results

Of the 501 incident cases, 62 declined participation and 17 had a colonoscopy for another reason than diarrhoea. Of the remaining 422 patients, 141 were lost to follow-up (e.g. death, withdrawal), and 61 did not reach the 5-year visit yet. Of the 220 cases with complete 5 year follow-up; 73% female, mean age 63 years; 46% had collagenous colitis (CC), 41% lymphocytic colitis (LC) and 13% incomplete MC. At baseline, 82% reported urgency, 44% nightly defecation, 39% faecal incontinence, and 47% moderate to severe functional impairment. A majority of 67% had active disease according to Hjortswang criteria¹. Treatment with budesonide was initiated in 51%, 29% was treated with loperamide or bulging agents, and 20% was not treated.
During 5-year follow-up, only 5% of the patients followed a quiescent disease course, i.e., no disease activity or treatment ever since diagnosis. Sustained clinical remission was achieved in 21%, 35% and 55% after 1, 3 and 5 years, respectively. In contrast, 33% had a relapsing disease course, and 7% exhibited a chronic active course with continuous activity and/or treatment. The disease course did not differ between CC and LC. Stool frequency at baseline was not predictive.
A quiescent disease course since diagnosis or achieving sustained clinical remission during the first or second year, was associated with a 70% chance of being in clinical remission after 5 years (p<0.001). In contrast, 57% of cases with a chronic active disease course in the first year had a chronic active or relapsing disease course throughout 5-year follow-up (p=0.02).
Patient reported symptom severity (SHS item 1) and interference of bowel symptoms with daily life (SHS item 2), significantly improved from baseline to year 1 and year 5 (both p<0.001). Cases with a quiescent course or achieved clinical remission after 5 years scored significantly better on SHS item 1 and 2, compared to those with relapsing or chronic disease activity (p<0.001).
At 5-year follow-up, 53 patients (24%) were on budesonide use, of which 47 (89%) had a relapsing or chronic disease course. Of those, almost one third used budesonide on demand and 8% used it continuously since diagnosis. Bulging agents (15%) and loperamide (21%) were regularly applied after 5 years, mainly in relapsing cases. Of those in clinical remission, 17% used loperamide on demand. Treatment with thiopurines (<1%) and biologicals (<2%) during follow-up was rare.

Conclusion

Five years after diagnosis, 40% of MC patients had a relapsing or chronic active disease course, resulting in an impaired quality of life. Disease activity at 1 year after diagnosis was predictive of activity after 5 years. Budesonide was the most frequently applied treatment, while use of immunosuppressants and biologicals was rare. Follow-up of MC patients should reflect the recurrent course of disease, and physicians should inform them accordingly. Randomised trials on alternatives to longtime budesonide use are warranted.

References

¹ Hjortswang et al, IBD 2009;15:1875-81

Disclosure

The PRO-MC project was primarily initiated after receiving the UEG LINK Award 2014

Introduction

Objective: Tumor necrosis factor–like cytokine 1A (TL1A) regulates pro-inflammatory cytokines and fibrosis. PRA023 is an anti-TL1A monoclonal antibody in development for multiple inflammatory/fibrotic diseases incorporating a precision approach with a predictive genetic-based diagnostic (Dx) tool. This placebo-controlled, double-blind phase 2 study assessed efficacy and safety of PRA023 induction treatment in adults with moderately to severely active ulcerative colitis (UC).

Aims & Methods

Patients with a modified Mayo score (mMS) of 4 to 9, centrally read endoscopy subscore of ≥2, rectal bleeding subscore of ≥1, and history of insufficient response, loss of response, and/or intolerance to conventional and/or advanced therapies (≤4 advanced agents from ≤3 classes allowed) were eligible. Patients were stratified by prior biologic exposure and Dx status and randomized 1:1 to placebo or intravenous PRA023 (1000 mg on day 1, 500 mg at weeks 2, 6, and 10). The primary endpoint was clinical remission per mMS at week 12. Analyses of ranked secondary endpoints were multiplicity-controlled.

Results

Of the 135 patients, 60/67 (89.6%) in the placebo arm and 68/68 (100%) in the PRA023 arm completed the 12-week induction period. Baseline characteristics were similar. A significantly greater proportion of patients who received PRA023 achieved the primary endpoint of clinical remission (26.5% PRA023 vs 1.5% placebo, ∆25.0%, p<0.0001) at week 12 (Table 1). All ranked secondary endpoints for cohort 1 significantly favored drug relative to placebo, including symptomatic remission (19.1% PRA023 vs 6.0% placebo, ∆13.1%, p=0.02), mucosal healing (30.8% PRA023 vs 3.5% placebo, ∆27.3%, p<0.0001), and IBDQ response (82.4% PRA023 vs 49.3% placebo, ∆33.1%, p<0.0001; Table 1). Exposure to prior advanced therapy, antidrug antibody status, and concomitant therapy did not have a major effect on efficacy. Statistically significant reductions in symptom scores (partial Mayo score) were observed in patients receiving PRA023 as early as week 2. C-reactive protein and fecal calprotectin levels were significantly reduced throughout the treatment period with PRA023 compared to placebo. An enhanced treatment effect was observed for the prespecified Dx+ subgroup, with 37.5% for both placebo-adjusted clinical remission and endoscopic improvement. The rates of treatment-emergent adverse events (AEs) were similar between the 2 arms with no serious AEs or AEs leading to study drug discontinuation in the PRA023 arm. There were no safety signals identified from the study.

Table 1: Primary and Secondary Efficacy Endpoints

Conclusion

PRA023 was effective with favorable tolerability for the induction of clinical remission and endoscopic improvement in moderately to severely active UC. A phase 3 study will be conducted to confirm these findings. The enhanced treatment effect in the Dx+ subgroup from cohort 1 is being further evaluated in the Dx+ expansion cohort 2.

Disclosure

BES has served as a consultant for or received speaker’s fees from AbbVie, Abivax, Adiso Therapeutics, Alimentiv, Amgen, Arena Pharmaceuticals, Artizan Biosciences, Artugen Therapeutics, AstraZeneca, Bacainn Therapeutics, Biora Therapeutics, Boehringer Ingelheim, Boston Pharmaceuticals, Bristol Myers Squibb, Calibr, Celltrion Healthcare, ClostraBio, Connect Biopharma, Cytoki Pharma, Eli Lilly and Company, Entera, Evommune, Ferring, Fresenius Kabi, Galapagos, Gilead, Genentech, GSK, Gossamer Bio, HMP Acquisition, Imhotex, Immunic, InDex Pharmaceuticals, Innovation Pharmaceuticals, Inotrem, Ironwood Pharmaceuticals, Janssen, Johnson & Johnson, Kaleido, Kallyope, Merck, MiroBio, Morphic Therapeutic, MRM Health, OSE Immunotherapeutics, Pfizer, Progenity, Prometheus Biosciences, Prometheus Laboratories, Protagonist Therapeutics, Q32 Bio, RedHill Biopharma, Sun Pharma Global, Surrozen, Synlogic, Takeda, Target RWE, Theravance Biopharma R&D, TLL Pharmaceutical, USWM Enterprises, Ventyx Biosciences, and Viela Bio and has received stock options from Ventyx Biosciences.
LPB has served as a consultant for or has received fees from AbbVie, Allergan, Alma, Amgen, Applied Molecular Transport, Arena, Biogen, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Celltrion Healthcare, Eli Lilly and Company, Enterome, Enthera, Ferring, Fresenius Kabi, Galapagos, Genentech, Gilead, Gossamer Bio, Hikma, Index Pharmaceuticals, Inotrem, Janssen, MSD, Mylan, Oppilan Pharma, OSE Immunotherapeutics, Nestlé, Norgine, Roche, Pandion Therapeutics, Pfizer, Pharmacosmos, Samsung Bioepis, Sandoz, sterna biologicals, Sublimity Therapeutics, Takeda, Theravance Biopharma, Tillotts Pharma, and Vifor; has received grants from AbbVie, Fresenius Kabi, MSD, and Takeda; and has stock options from CTMA.
SD has received consultancy fees from AbbVie, Alimentiv, Allergan, Amgen, Applied Molecular Transport, AstraZeneca, Athos Therapeutics, Biogen, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Celltrion Healthcare, Dr. Falk Pharma, Eli Lilly and Company, Enthera, Ferring, Gilead, Hospira, Inotrem, Janssen, Johnson & Johnson, Morphic, MSD, Mundipharma, Mylan, Pfizer, Roche, Sandoz, Sublimity Therapeutics, Takeda, Teladoc Health, TiGenix, UCB Inc., Vial, and Vifor and lecture fees from AbbVie, Amgen, Ferring, Gilead, Janssen, Mylan, Pfizer, and Takeda.
DTR has served as a consultant for AbbVie, AltruBio, Aslan Pharmaceuticals, Athos Therapeutics, Bellatrix Pharmaceuticals, Boehringer Ingelheim, Bristol Myers Squibb, Celgene Chronicles, Corp/Syneos, ClostraBio, Connect Biopharma, Eco R1, Eli Lilly and Company, Genentech/Roche, Gilead Sciences, Iterative Health, Janssen Pharmaceuticals, Kaleido, Pfizer, Prometheus Biosciences, Reistone Biopharma, Seres Therapeutics, Takeda, Target RWE, and Trellus Health and has received grant support from Takeda, Helmsley Charitable Trust, and the Gastro-Intestinal Research Foundation.
SV has received grants from AbbVie, Galapagos, Johnson & Johnson, Pfizer, and Takeda and consulting and/or speaking fees from AbbVie, Abivax, AbolerIS Pharma, AgomAb, Alimentiv, Arena, AstraZeneca, Avaxia, Bristol Myers Squibb, Boehringer Ingelheim, Celgene, CVasThera, Cytoki Pharma, Dr. Falk Pharma, Ferring, Galapagos, Genentech/Roche, Gilead, GSK, Hospira, IMIDomics, Janssen, Johnson & Johnson, Eli Lilly and Company, Materia Prima, MiroBio, Morphic, MrMHealth, Mundipharma, MSD, Pfizer, ProDigest, Progenity, Prometheus, Robarts Clinical Trials, Second Genome, Shire, Surrozen, Takeda, Theravance, Tillotts Pharma, and Zealand Pharma.
OL, AL, DDN, and JDL are employees and shareholders of Prometheus Biosciences.
AWK has nothing to disclose.
JL has received speaker fees from AstraZeneca, MSD, Janssen, and Gilead and research grants from Johnson & Johnson.
RK has received grants from Janssen and Takeda.
JK has received consultation fees, research grants, or honoraria from AbbVie, Egis, Janssen, Nestlé, Nutricia, and Takeda.
CM has received consulting fees from AbbVie, Alimentiv, Amgen, AVIR Pharma, BIOJAMP, Bristol Myers Squibb, Celltrion Healthcare, Ferring, Fresenius Kabi, Janssen, McKesson, Mylan, Takeda, Pendopharm, Pfizer, Prometheus Biosciences, Roche, and Sanofi; speaker's fees from AbbVie, Amgen, AVIR Pharma, Alimentiv, Bristol Myers Squibb, Ferring, Fresenius Kabi, Janssen, Takeda, Pendopharm, and Pfizer; royalties from Springer Publishing; and research support from Ferring and Pfizer.
TER has been a speaker for Takeda Pharmaceuticals, Janssen, Pfizer, Bristol Myers Squibb, and Abbvie; has served on advisory boards for AbbVie, Ardelyx, Arena, Boehringer Ingelheim, Bristol Myers Squibb/Celgene, Eli Lilly and Company, Ferring, Genentech/Roche, Gilead, Intercept, Iterative Scopes, Janssen, Pfizer, Prometheus Biosciences, Sanofi, and Takeda; and has been a shareholder for Iterative Scopes.
RP has been a consultant for Abbott, AbbVie, Abivax, Alimentiv (formerly Robarts), Amgen, Arena, AstraZeneca, Biogen, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Celltrion Healthcare, Cosmos Pharmaceuticals, Eisai, Elan, Eli Lilly and Company, Ferring, Galapagos, Fresenius Kabi, Genentech, Gilead Sciences, GSK, BIOJAMP, Janssen, Merck, Mylan, Novartis, Oppilan Pharma, Organon, Pandion, Pendopharm, Pfizer, Progenity, Prometheus Biosciences, Protagonist Therapeutics, Roche, Sandoz, Satisfai Health, Shire, Sublimity Therapeutics, Takeda, Theravance Biopharma, Trellus, Viatris, Ventyx, and UCB; has received speakers fees from AbbVie, Amgen, Arena, Bristol Myers Squibb, Celgene, Eli Lilly and Company, Ferring, Fresenius Kabi, Gilead Sciences, Janssen, Merck, Organon, Pfizer, Roche, Sandoz, Shire, and Takeda; and has served on advisory boards for AbbVie, Alimentiv (formerly Robarts), Amgen, Arena, AstraZeneca, Biogen, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Eli Lilly and Company, Ferring, Fresenius Kabi, Genentech, Gilead Sciences, GSK, BIOJAMP, Janssen, Merck, Mylan, Novartis, Oppilan Pharma, Organon, Pandion Pharma, Pfizer, Progenity, Protagonist Therapeutics, Roche, Sandoz, Shire, Sublimity Therapeutics, Takeda, and Ventyx.
BGF has served as a consultant for AbbVie, AbolerIS Pharma, AgomAb, AllianThera, Amgen, AnaptysBio, Applied Molecular Transport, Arena, Avoro Capital Advisors, Atomwise, BIOJAMP, Biora Therapeutics, Boehringer Ingelheim, Boxer, Celsius Therapeutics, Bristol Myers Squibb/Celgene, Connect Biopharma, Cytoki, Disc Medicine, Duality, EcoR1 Capital, Eli Lilly and Company, Equillium, Ermium, First Wave, First Word Group, Galapagos, Galen Atlantica, Genentech/Roche, Gilead, Gossamer Bio, GSK, Hinge Bio, HotSpot Therapeutics, Index Pharma, Imhotex, Immunic Therapeutics, JAK Academy, Janssen, Japan Tobacco, Kaleido, Landos Biopharma, Leadiant, L.E.K. Consulting, Lenczner Slaght, LifeSci Capital, Lument AB, Millennium, MiroBio, Morgan Lewis, Morphic Therapeutics, Mylan, OM Pharma, Origo Biopharma, Orphagen, Pandion Pharma, Pendopharm, Pfizer, Prometheus Therapeutics, PlayToKnow AG, Progenity, Protagonist Therapeutics, PTM Therapeutics, Q32 Bio, Rebiotix, REDX, Roche, Sandoz, Sanofi, Seres Therapeutics, Silverback Therapeutics, Surrozen, Takeda, Teva, Thelium, TiGenix, Tillotts Pharma, Ventyx Biosciences, VHsquared, Viatris, Ysios, Ysopia, Zealand Pharma; on the speaker’s bureau for AbbVie, Janssen, and Takeda; and on advisory boards for AbbVie, Amgen, AMT, AnaptysBio, Boehringer Ingelheim, Bristol Myers Squibb/Celgene, Eli Lilly and Company, Genentech/Roche, Janssen, MiroBio, Origo BioPharma, Pfizer, Prometheus, REDX, Sanofi, Takeda, Tillotts Pharma, Teva, Progenity, Index, EcoR1 Capital, Morphic, GSK, and Axio Research.
ST has received consulting fees from Robarts Clinical Trials and Prometheus Biosciences and owns stock in Prometheus Biosciences; is a member of steering committees of Janssen, AbbVie, Boehringer Ingelheim, Gilead, Celgene, and Bristol Meyers Squibb; has received speaker honoraria from AbbVie, Takeda, Janssen, Ferring, Pfizer, and Celltrion; and has served on advisory committees of Janssen, Takeda, AbbVie, Eli Lilly, Pfizer, Gilead, Galapagos, and Roche.
DPBM has received consulting fees from Prometheus Biosciences, Prometheus Laboratories, Gilead Sciences, Boehringer-Ingelheim, Pfizer, Prometheus Laboratories, Takeda, Palatin Technologies, and owns stock in Prometheus Biosciences.

Introduction

In UC, biologics and other targeted therapies generally show overall remission rates of less than 50% after one year using regulatory endpoints, as defined by patient reported outcomes (PRO): rectal bleeding and stool frequency in conjunction with endoscopic improvement. For IBD patients, achieving full control of symptoms quickly after therapy start leads to better long-term outcomes. Traditional landmark endpoints to define success of treatment have shown mixed success in the real world. Machine learning approaches using dynamic individual patient-level data could be better suited to derive patterns and to identify responder sub-populations early in the treatment paradigm. We used VARSITY (NCT02497469) dataset (1) to derive trajectories of response to vedolizumab (VDZ) and adalimumab (ADA) in conjunction with a disease control (DC) endpoint at week 52. Our aim was to use an unbiased clustering to deconvolute the clinical phenotype of UC under two therapies to identify common patterns of response delivered by each therapeutic intervention.

Aims & Methods

DC at week 52 was previously defined as a combination endpoint of clinical, endoscopic and histological response with CRP/FcP normalization (2, 3). The full set of daily patient-reported daily outcome recordings over 52 weeks was subjected to an unsupervised machine learning algorithm (Group-Based Multivariate Trajectory Modeling). The BIC criterion was used to determine the optimal number of clusters. After visual examination of disease trajectories, we manually merged similar trajectories.

Results

We identified four distinct patient clusters in the dynamic PRO data collected over 52 weeks: Super-Response (SR), Response (R), Partial Response (PR) and Incomplete/Non-Response (INR). In SR and R clusters, up to 30% of patients reached DC, regardless of treatment, whereas patients in PR and INR groups had almost no chance to reach DC. SR and R groups in the VDZ arm had twice as many patients who reached DC at week 52 compared with ADA (n=39 vs n=17, respectively). SR was seen 5 times more frequently with VDZ (170 patients [pts]) than with ADA treatment (27 pts). Our findings confirm previous supervised analyses, in which early remission at week 6 predicts remission and DC at week 52 under VDZ but not under ADA.

Conclusion

We demonstrate that the dynamics of the disease course under therapy can be used to identify meaningful subpopulations in UC. The observed heterogeneity cannot be explained by baseline demographic/disease characteristics and may represent different pathophysiologies of UC. Super-responders have the highest chances to achieve DC. The large level of differentiation between ADA and VDZ highlights the power of the analysis to discriminate drug efficacies in a comparative setting. If super-response is not achieved under ADA, patients might be switched to other therapies as early as after 4 weeks. Further work is necessary to prospectively investigate response trajectories in different MoAs. Eventually, disease trajectories may become an important monitoring tool for personalized medicine and clinical decision-making.

References

(1) Sands BE et al. (2019) N Engl J Med 381:1215–1226.
(2) Danese S et al. (2021) J Crohns Colitis 15:S305–S305.
(3) Schreiber S et al (2023) J Crohns Colitis 17:863-875.

Disclosure

Funding: European Commission (3TR), Excellence Cluster PMI and Takeda.
S. Schreiber reports consultancy and personal fees from AbbVie, Arena, BMS, Biogen, Celltrion, Celgene, Dr Falk, Ferring, Fresenius, Gilead, HIKMA, IMAB, Janssen, MSD, Mylan, Pfizer, Protagonist, Provention Bio, Sandoz, Takeda and Theravance.
D. Ostanin, J. Cheng, C. Agboton, V. Yajnik and P. Thakker are employees of Takeda and hold stock/stock options in Takeda.