Austrian infliximab experience in Crohn's disease: a nationwide cooperative study with long-term follow-up

Parvovirus-B19-associated fulminant myocarditis successfully treated with immunosuppressive and antiviral therapy

Fulminant myocarditis is a rare inflammatory heart disease affecting relatively young adults. We describe a case of a 27-year-old male with acute onset severe heart failure. A rapid and accurate diagnostic approach suggested parvovirus B19 as the most probable cause for this fulminant viral myocarditis. Initial haemodynamic support, intensive immunosuppressive and antiviral therapy resulted in a complete recovery within 2 weeks. This case demonstrates the importance of a detailed diagnosis, allowing better classification of the underlying pathology and subsequent targeted treatment.

A decade of infliximab: The Austrian evidence based consensus on the safe use of infliximab in inflammatory bowel disease

Infliximab (IFX) has tremendously enriched the therapy of inflammatory bowel diseases (IBD) and other immune mediated diseases. Although the efficacy of IFX was undoubtedly proven during the last decade numerous publications have also caused various safety concerns. To summarize the immense information concerning adverse events and safety issues the Austrian Society of Gastroenterology and Hepatology launched this evidence based consensus on the safe use of IFX which covers the following topics: infusion reactions and immunogenicity, skin reactions, opportunistic infections (including tuberculosis), non-opportunistic infections (bacterial and viral), vaccination, neurological complications, hepatotoxicity, congestive heart failure, haematological side effects, intestinal strictures, stenosis and bowel obstruction (SSO), concomitant medication, malignancy and lymphoma, IFX in the elderly and the young, mortality, fertility, pregnancy and breast feeding. To make the vast amount of information practicable for routine application the consensus was finally condensed into a checklist for a safe use of IFX which consists of two parts: issues to be addressed prior to anti-TNF therapy and issues to be addressed during maintenance. Both parts are further divided into obligatory and facultative items.

Systematic review: steroid withdrawal in anti-TNF-treated patients with inflammatory bowel disease

BACKGROUND

The increasing awareness of increased risk for opportunistic infections when combining several immunosuppressant drugs led to new treatment goals for inflammatory bowel disease including limited use of steroids.

AIM

To conduct a systematic review to establish figures for steroid withdrawal in anti-TNF treated inflammatory bowel disease-patients.

METHODS

Medline was searched using the search-terms Ulcerative Colitis (UC) [Mesh], Crohn Disease (CD) [Mesh], IBD [Mesh], crohn, colitis, IBD and steroid sparing, all combined with infliximab and adalimumab. We selected English-language publications that addressed the effect of anti-TNF on steroid withdrawal. Studies had to assess patients with luminal CD or UC. Numbers of patients who were able to withdraw steroids were calculated.

RESULTS

Six studies could be included; five reporting on infliximab and one on adalimumab. Studies were heterogeneously designed. Overall, in the adult population, up to 38% of the patients were able to withdraw corticosteroids during infliximab therapy. In the paediatric population, up to 75% of the patients were able to withdraw corticosteroids during infliximab therapy.

CONCLUSIONS

Although a consensus on the definition of steroid-sparing is lacking, approximately two-thirds of the inflammatory bowel disease-patients are unable to withdraw corticosteroid treatment during anti-TNF therapy.

Update on the risk of lymphoma following immunosuppressive therapy for inflammatory bowel disease

The care of inflammatory bowel disease has changed considerably with the introduction of a number of immunosuppressants including anti-metabolite and anti-TNF therapies. While efficacious, these medications also carry important risks, notably the potential risk of lymphoma. This risk is one of the most worrisome for both patients and physicians. Our current knowledge is still evolving; however, our understanding of what risks these drugs carry, both individually and synergistically, is critical in allowing informed decision making. In this article, we will describe the known lymphoma risks of commonly used immunosuppressant medications in inflammatory bowel disease, with an emphasis on non-Hodgkin's lymphoma and hepatosplenic T-cell lymphoma.

Safety profile of IBD: lymphoma risks

This article describes the cancer risks of commonly used inflammatory bowel disease (IBD) medications, with an emphasis on hematologic malignancy risks. The increasing use of immunosuppressant therapies in the treatment of IBD has raised this question to an even greater importance. Studies evaluating these medications are complicated due to varying disease severity and concomitant use of other immunosuppressant medication. The potential risks of all therapies must be weighed against the benefits these therapies can offer these patients.

Safety profile of IBD: lymphoma risks

This article describes the cancer risks of commonly used inflammatory bowel disease (IBD) medications, with an emphasis on hematologic malignancy risks. The increasing use of immunosuppressant therapies in the treatment of IBD has raised this question to an even greater importance. Studies evaluating these medications are complicated due to varying disease severity and concomitant use of other immunosuppressant medication. The potential risks of all therapies must be weighed against the benefits these therapies can offer these patients.

Long-term response rates to infliximab therapy for Crohn's disease in an outpatient cohort

BACKGROUND

Infliximab's efficacy in the induction and maintenance of remission in luminal Crohn's disease has been confirmed by randomized, controlled trials. Less clearly described are long-term outcomes in the clinical practice setting since the establishment of regularly scheduled, every eight-week maintenance infliximab infusions. Existing reports describing clinical practice outcomes are limited by short durations of follow-up or by the use of episodic dosing, or focus on safety data rather than clinical outcomes.

OBJECTIVE

To examine induction and maintenance responses to infliximab in an outpatient inflammatory bowel disease clinic.

METHODS

A retrospective chart review was performed. Clinical outcomes were infliximab induction and maintenance responses, defined as the ability to stop and remain off corticosteroids while not requiring additional therapy for active disease.

RESULTS

One hundred thirty-three patients were identified with records sufficiently detailed to be analyzed. Of these, 117 patients (88%) demonstrated a clinical response to induction; 104 of 117 (89%) were on concomitant immunosuppressive therapy; 80 of 104 on azathioprine/6-mercaptopurine (77%); and 24 of 104 on methotrexate (23%). The mean duration of clinical response was 94 weeks (95% CI 78.8 to 109.2). The proportion of patients who maintained response at 30 weeks was 83.2%, at 54 weeks was 63.6% and at 108 weeks was 44.9%. Adverse events occurred for 15 of 117 patients (12.8%), consisting of nine infusion reactions, four serum sickness-like reactions, one rash and one infection.

CONCLUSION

Patients treated with infliximab therapy for luminal Crohn's disease in our outpatient clinic achieved excellent induction and maintenance of response rates, confirming the real-life efficacy of maintenance infliximab established in clinical trials.

A case of small bowel adenocarcinoma in a patient with Crohn's disease detected by PET/CT and double-balloon enteroscopy

Small bowel adenocarcinoma (SBA) in patients with Crohn's disease (CD) is quite rare, difficult to diagnose without surgery, and has a poor prognosis. Here, we report a 48-year-old man with SBA and a 21-year history of CD who was diagnosed by a combination of positron emission tomography/computed tomography (PET/CT) and double-balloon enteroscopy (DBE). Since the age of 27 years, the patient had been treated for ileal CD and was referred to our hospital with persistent melena. Multiple hepatic tumors were found by CT. PET/CT detected an accumulation spot in the small bowel. DBE revealed an ulcerative tumor in the ileum about 100 cm from the ileocecal valve. An endoscopic forceps biopsy specimen showed poorly differentiated adenocarcinoma. There were some longitudinal ulcer scars near the tumor, and the chronic inflammation in the small bowel appeared to be associated with the cancer development. Previous reports suggest the risk of SBA in patients with CD is higher than in the overall population. Since early diagnosis is extremely difficult in these cases, novel techniques, such as PET/CT and DBE, may be expected to help in making a preoperative diagnosis of the development of SBA in CD.

Long-term durability of Crohn's disease treatment with infliximab

BACKGROUND

There is a paucity of data providing insight into the durability of Crohn's disease treatment with infliximab for periods longer than 12 months. Our aim was to assess the long-term durability of infliximab therapy.

MATERIALS AND METHODS

A total of 198 Crohn's patients under a maintenance regimen with infliximab, with at least a 30-month follow-up, were evaluated retrospectively. Long-term response maintenance was estimated using Kaplan-Meier analysis. The effect of specific variables was calculated using logistic regression and proportional hazard regression analyses.

RESULTS

Maintenance of response rates at 72 months was estimated to be 66.4% for initial responders and 58.2% for all patients treated. Concurrent immunomodulators enhanced response maintenance in all patients treated, particularly if started >3 months before the initiation of infliximab therapy. Smoking significantly decreased the maintenance of response in initial responders.

CONCLUSIONS

Infliximab treatment of Crohn's disease is reasonably durable beyond 12 months. Concurrent immunosuppressive therapy may increase - and smoking may decrease - long-term response maintenance.

Small bowel adenocarcinoma in Crohn’s disease: A case report and review of literature

Small bowel adenocarcinomas are remarkable for their rarity, difficult diagnosis and poor prognosis. Here we report an unusual case of a 33-year-old patient in whom infiltrative adenocarcinoma of the small bowel was diagnosed after a 10-year history of Crohn’s disease. In most previously reported cases, detection of Crohn’s disease was subsequent to that of carcinoma of the small bowel or the patients involved had an even longer history of the disease. Our literature review suggests that the risk of small bowel adenocarcinoma is higher in patients with Crohn’s disease than in the overall population. We present details on epidemiology as well as clinical and diagnostic aspects of this rare disease entity.

Infliximab for the treatment of psoriasis: Clinical experience at the State University of New York at Buffalo

BACKGROUND

Infliximab has shown promising results for the treatment of moderate to severe psoriasis and psoriatic arthritis.

METHODS

We conducted a retrospective study of all 52 patients treated with intravenous infliximab for severe psoriasis at a single practice site. These patients had recalcitrant plaque psoriasis (>33% body surface area), which was unresponsive to multiple conventional systemic therapies. Intravenous infliximab was administered at a dose of 5 mg/kg at 0, 2, 6, and 14 weeks and every 8 weeks thereafter. Patients were monitored for infections, infusion reactions, side effects, and response to therapy.

RESULTS

Fifty-two patients (men = 32, women = 20) with a mean age of 47 (range, 22-76 years old) were included in this study. They were followed for a minimum of 4 months and a maximum of 33 months (median, 22 months). Patients received a mean total number of 12 infusions (range, 3-22). Forty-six of 52 patients (88%) had a clear or almost clear improvement based on the Physician's Global Assessment done by a single physician. Twelve patients (23%) required infliximab dose escalation to maintain control of their disease. Nine patients experienced infusion reactions. Thirteen patients experienced nonopportunistic infections; however, only one infection required temporary cessation of infliximab.

LIMITATIONS

This was a retrospective study at a single practice site.

CONCLUSION

Infliximab was extremely effective and well tolerated in this group of patients with severe, recalcitrant psoriasis. Thirty-nine of 52 patients have continued receiving treatment for a median duration of 25 months with excellent disease control. Infliximab can provide control of extensive psoriasis with continued intermittent infusions.

The risk of lymphoma in the treatment of inflammatory bowel disease with immunosuppressive agents

Immunosuppressive agents have become an established part of the therapeutic armamentarium for inflammatory bowel disease (IBD). However, when used in transplant recipients or for other indications, agents that suppress or modulate the immune system (immunomodulators) have been associated with an increased risk of lymphoma. Fortunately, in part because of the lower doses used in IBD patients, the risk of lymphoma in IBD patients appears to be significantly less than that associated with renal and hepatic transplant-related immunosuppression. Whether the risk of azathioprine or 6-mercaptopurine associated lymphoma in IBD is real or relates to the underlying disease remains unclear. The results of several recent large well designed population-based studies suggest that the lymphoma risk associated with azathioprine and 6-mercaptopurine therapy is likely to be of minimal clinical significance compared to the established and more frequent risks of myelosuppression and infection, and is far outweighed by the clinical benefit of immunomodulator therapy in IBD. While the issue of lymphoma risk is likely to become more relevant with the growing number of biologic and immunomodulators being tested in clinical trials for IBD, early post-marketing surveillance data on infliximab suggests that the lymphoma risk may not be any greater than that associated with azathioprine and 6-mercaptopurine.