Antibiotic use differentially affects the risk of anti-drug antibody formation during anti-TNFα therapy in inflammatory bowel disease patients: a report from the epi-IIRN.

Anti-drug antibodies (ADA) to anti-tumour necrosis factor (anti-TNF) therapy drive treatment loss of response. An association between intestinal microbial composition and response to anti-TNF therapy was noted. We therefore aimed to assess the implications of antibiotic treatments on ADA formation in patients with inflammatory bowel disease (IBD). We analysed data from the epi-IIRN (epidemiology group of the Israeli IBD research nucleus), a nationwide registry of all patients with IBD in Israel. We included all patients treated with anti-TNF who had available ADA levels. Survival analysis with drug use as time varying covariates were used to assess the association between antibiotic use and ADA development. Next, specific pathogen and germ-free C57BL mice were treated with respective antibiotics and challenged with infliximab. ADA were assessed after 14 days. Among 1946 eligible patients, with a median follow-up of 651 days from initiation of therapy, 363 had positive ADA. Cox proportional hazard model demonstrated an increased risk of ADA development in patients who used cephalosporins (HR=1.97, 95% CI 1.58 to 2.44), or penicillins with β-lactamase inhibitors (penicillin-BLI, HR=1.4, 95% CI 1.13 to 1.74), whereas a reduced risk was noted in patients treated with macrolides (HR=0.38, 95% CI 0.16 to 0.86) or fluoroquinolones (HR=0.20, 95% CI 0.12 to 0.35). In mice exposed to infliximab, significantly increased ADA production was observed in cephalosporin as compared with macrolide pretreated mice. Germ-free mice produced no ADA. ADA production is associated with the microbial composition. The risk of ADA development during anti-TNF therapy can possibly be reduced by avoidance of cephalosporins and penicillin-BLIs, or by treatment with fluoroquinolones or macrolides.

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Competing interests: YC received research grants, speaker and advisory fees from AbbVie; speaker and advisory fees from Janssen; grant, speaker and advisory fees from Takeda and consultancy fees from CytoReason. SSO received grant funding from Takeda, holds equity and receives consultancy fees from CytoReason. SG-V declares CytoReason advisory fees for last 3 years. RK received consultation fee, research grant, royalties or honorarium from Takeda and Pfizer. ID received consultation fee, research grant or honorarium from Janssen, AbbVie, Takeda, Pfizer, Roche/Genentech, Celgene/BMS, Arena, Neopharm, Gilead, Gallapagos, Celltrion, Ferring, Falk Pharma, MSD, DSM, Cambridge Healthcare, Sublimity, Sangamo, Nestle, Wild bio, Food Industries Association, Integran Holdings, Abbott, Altman Research