Case report

Cristina Radu

Generalities

I.M., 39 yrs, female Urban Non-smoker, no alcohol use

Personal History
Nonspecific Inflammatory Bowel Disease since 1995 Colonic Crohns Disease stenosing and fistulising pattern since 2007 - stricture of the anal channel digitally dilated in Jan 2009 - stricture of the sigmoid colon endoscopic dilation in Jan 2009 Perianal fistula Erythema nodosum May 2009

September 2009
Symptoms 4 loose stools/day, diurnal, no blood Physical examinaton normal weight perianal fistulous orifice Biological examination inflammatory syndrome (fibrinogen=660mg/dl, WBC=5150/mm3) mild secondary anemia (HGB=9.9g/dl, MCV=73fl, MCHC=30.3g/dl)

Treatment so far

Multiple applications of systemic corticosteroids Maintenance treatment with Azathioprine 125 mg/day (2.5mg/kgc/day) since May 09 Ciprofloxacin 500 mg b.i.d.

Which therapy should we choose next?

ECCO Statement 5D

Active colonic CD may be treated with sulfasalazine if only mildly active, or with systemic corticosteroids

For those who have relapsed, azathioprine or mercaptopurine should be added, or, if intolerant, methotrexate should be considered
Infliximab should be considered in addition for corticosteroid or immunomodulator refractory disease or intolerance, although surgical options should also be considered

Evolution

Two Infliximab applications 5mg/kgc i.v. (21.09 and 05.10) 03.11 admission for perianal pain (48 hrs history) Biological examination:
mild secondary anemia (HGB=9.8g/dl MCHC=32.3g/dl) inflammatory syndrome (fibrinogen=582mg/dl)

Colonoscopy

Perianal fistulous orifice & perianal induration Stricture of the anal channel digitally dilated Inflammatory stricture at 40cm Cobblestone aspect Perforation risk

Pelvic CT scan

Inflammatory signs wall of the rectum, sigmoid and descendent colon (thickening, edema) Small perirectal and perineal abscesses (17/26mm) with associated fibrosis

Treatment

Surgical drainage Temporization of the biological therapy Initiation of CS therapy (MTP 40mg/day i.v.) Azathioprine 125mg/day Ciprofloxacin 500mg b.i.d. and Metronidazole 250mg t.i.d.

Reevaluation after one month

Clinical examination: normal weight, 3 stools/day, diurnal, normal consistency

Biological tests: mild anemia (Hb=10.6g/dl), inflammatory syndrome in remission (fibrinogen=) Colonoscopy: complex perianal fistula, mild Crohns disease lesions (pseudopolips, no strictures)

Surgical consult: no signs of local inflammation or perianal abscesses

Treatment

Oral CS Azathioprine 125mg/day Metronidazole 250mg, t.i.d Third Infliximab application (15.12 10 wks after the second one)

The role of biological agents in Crohns disease therapy

Rapid induction and long-term maintenance of clinical and endoscopic remission in luminal and fistulising forms Maintenance of remission without CS Control of extraintestinal manifestations Avoidance of hospitalization and surgery Decrease in complications rate QOL improvement

Available biological agents

Infliximab - mouse-human chimeric monoclonal antibody to TNF- Adalimumab - humanized recombinant antibody to TNF- Certolizumab pegol - Fab fragment of a humanized antiTNF- monoclonal antibody Natalizumab anti-4-integrin monoclonal antibody

Indications of Infliximab Therapy for IBD

Moderately to severely active luminal Crohns disease induction and maintenance of remission Active fistulizing Crohns disease induction and maintenance of remission UC Crohns disease in children

TNF- effects

macrophage activation (autocrine) induction of proinflammatory cytokines IL1 and IL6 induction of cell adhesion molecules procoagulant granulocytes activation and degranulation production of MMP, direct tissue injury

Infliximab efficiency

ACCENT1: maintenance infliximab therapy in patients with active Crohns disease

39 to 45% of pts treated with infliximab who had an initial response (wk 2) maintained remission after 30 weeks vs 21% on placebo Mean maintenance of remission was 38 to 54 weeks compared with 21 weeks for patients who received placebo treatment

ACCENT2: maintenance infliximab therapy in patients with abdominal or perianal fistulas

At week 54, 36% of patients in the infliximab maintenance group had a complete absence of draining fistulas, as compared with 19% of patients in the placebo maintenance group

Dosage and administration

5 mg/kg given as an intravenous induction regimen at 0, 2 and 6 weeks (2 hrs infusion) maintenance regimen of 5 mg/kg every 8 weeks for adult patients who respond and then lose their response, consideration may be given to treatment with 10 mg/kg

Antibodies to Infliximab

The incidence of antibodies to infliximab in patients given a 3-dose induction regimen followed by maintenance dosing was approximately 10% A higher incidence of antibodies in Crohns disease pts after drug free intervals >16 weeks The majority of antibody-positive patients had low titers Patients who were antibody positive were more likely to have higher rates of clearance, reduced efficacy and to experience an infusion reaction Antibody development was lower among pts receiving immunosuppressant therapies

Adverse effects
1)

Infusion reactions (6%)

- headache, dizziness, nausea, injection-site irritation, flushing, chest pain, dyspnea, and pruritus - respond to slowing the infusion rate or treatment with antihistamines, paracetamol, and sometimes corticosteroids - 16% among patients positive for antibodies to infliximab - the lowest incidence occurred among patients receiving both steroids and immunosuppressives - generally seen after one to five maintenance infusions

Adverse effects
2) A delayed reaction of joint pain and stiffness, fever, myalgia and malaise may occur, especially if there has been an interval more than one year after a previous infusion. Pre-treatment with hydrocortisone is advised in these circumstances.

Adverse effects
3) Infections (36%) - most frequent: upper respiratory tract infections and urinary tract infections - severe infections (4%): pneumonia, cellulitis, abscess, skin ulceration, sepsis - screening for infections: CBC, PCR, chest X-ray, PPD skin test, AgHBs, anti-HBs, antiHBc, anti-HCV, anti-HIV

Latent TB

Chemoprophylaxis with hydrazide 300mg/day (5mg/kgc/day) Maximum benefit 9 months Clinical practice 6-9 months Initiation of chemoprophylaxis one month before IFX therapy begins

Papa A, et al. Am J Gastroenterol 2009 (clinical review); 104:1575

Adverse effects
4) Autoantibodies/Lupus-like Syndrome - anti-dsDNA (34%) and ANA (56%) - very rare lupus-like syndrome 5) Malignancies - no cause-effect association between IFX and global cancer risk in IBD pts - conflicting data concerning LMNH risk - hepato-splenic T-cell lymphoma in young IBD pts treated with IFX and thiopurines (16 cases) 6) Heart failure agravation
Biancone L. et al. Nat Clin Pract Gastroenterol Hepatol 2007; 4: 78
Lichtenstein GR et al. Am J Gastroenterol 2008; 103: S436

Contraindications

severe infections (TB or others) pregnant or nursing women moderate to severe congestive heart failure solid and hematological tumors with evolving potential in the past 5 yrs (absolute) premalignant conditions (colonic and urinary polyps, myelodysplasia, uterine cervical dysplasia - relative)

Conclusions

Indications for Infliximab in Crohns disease include moderate to severe active luminal or fistulous disease Infliximab proved to be an efficient treatment under these conditions The main concern during therapy is the risk of infection, therefore screening for infection is of critical importance