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Ustekinumab is a monoclonal antibody targeting interleukin 12 and interleukin 23 pathways in the treatment of IBD, widely used in both adult and paediatric populations with reported safety and efficacy in achieving clinical remission. 1 2 This review was prompted by 3 significant adverse reactions requiring resuscitation with 2/3 children receiving IM Adrenaline for suspected anaphylaxis.The prospective local data base of all children diagnosed with IBD 2019–24, total 450, was reviewed and those treated with Ustekinumab were included in the study. 32 patients were prescribed Ustekinumab. 20/32 were males. Age at start of treatment was 8.75–17.75 years and time from diagnosis to starting Ustekinumab was 5 months-9.25 years, mean of 3.6 years. 26/32 patients were diagnosed with Crohn’s disease, 4 with ulcerative colitis, 1 with VEOIBD and 1 with IBDU. All patients had received prior, optimised, anti TNF treatment, 17 had received both Infliximab and Adalimumab. 9 patients had also received Vedolizumab (alpha 4 beta 7 integrin uptake blocker), and one Tofacitinib (JAK inhibitor).At the time of data collection 14 children (43.75%) remained on Ustekinumab and of those 11 (34.37%) had been on it for 6 months or longer.3 children experienced anaphylactoid reactions to the initial intravenous loading dose, 2 received IM adrenaline and oxygen. Serum tryptase was not raised in any of the cases. Although tryptase is commonly raised in anaphylaxis this is not always the case. These children switched therapies immediately.Data for calprotectin levels was available for 27 children. 92% children had a calprotectin >200 at the beginning of treatment, with 63% >800. At three months 60% of children had a reduction in calprotectin levels but over a third, 36% remained >800. Data available for 11 children remaining on Ustekinumab > 6 months showed that half (53%) were in probable mucosal remission with faecal calprotectin <200, with a third (33%) showing clinical improvement but ongoing mucosal inflammation, calprotectin >800.9/29 children were clinically well when commencing Ustekinumab treatment. Medication change was because of high calprotectin results, MRE results and adverse skin reactions to anti TNF treatment. At 6 months 8/9 children remained on Ustekinumab, 5 had no clinical symptoms, but 3 patients reported worsening symptoms. 5/6 children swapped due to adverse skin reactions to anti TNF reported improvement.20/29 children had significant IBD clinical symptoms when starting Ustekinumab. 16/20 (80%) saw some improvements at 3 months. At 6 months 8/20 (40%) reported improved symptoms and were still on Ustekinumab. 12/40 (60%) reported no improvement or deterioration in their original symptoms, or had stopped the medication.7/29 (24%) children, lost response to Ustekinumab after making initial improvements, when the intervals between injections was extended children (4–8 weekly) showed signs of relapse. This may suggest that more frequent dosing and/or reloading with IV doses may improve outcomes.3 Drug levels for Ustekinumab were not available at the centre.It is important to be aware of potential rare but significant adverse events when selecting medication and counselling families.References Feagan B, Sandborn W, Gasink C, et al. Ustekinumab as induction and maintenance therapy for Crohn’s disease. N Eng J Med. 2016 Nov 17;375(20):1946–60.Ghosh S, Feagan B, Ott E, et al. Safety of ustekinumab in inflammatory bowel disease: pooled safety analysis through 5 years in Crohn’s disease and 4 years in ulcerative colitis. Journal of Crohn’s and Colitis 2024;18(7):1091–1101.Meserve J, Ma C, Dulai P, et al. Effectiveness of reinduction and/or dose escalation of ustekinumab in Crohn’s disease: a systematic review and meta-analysis. Clinical Gastroenterology and Hepatology 2022;20:12.