Treatment of luminal and fistulizing Crohn's disease with infliximab

Accelerated Infliximab Induction for Severe Lower Gastrointestinal Bleeding in a Young Patient with Crohn’s Disease: A Case Report

BACKGROUND

Severe lower gastrointestinal bleeding (SLGIB) is a rare complication of Crohn's disease (CD). The treatment of these patients is a clinical challenge. Monoclonal anti-TNFα antibody (IFX) can induce relatively fast mucosal healing. It has been reported for the treatment of SLGIB, but there are few reports on accelerated IFX induction in CD patients with SLGIB.

CASE SUMMARY

A 16-year-old boy with a history of recurrent oral ulcers for nearly 1 year presented to the Gastroenterology Department of our hospital complaining of recurrent periumbilical pain for more than 1 mo and having bloody stool 4 times within 2 wk. Colonoscopy showed multiple areas of inflammation of the colon and a sigmoid colon ulcer with active bleeding. Hemostasis was immediately performed under endoscopy. The physical examination of the patient showed scattered small ulcers in the lower lip of the mouth and small cracks in the perianal area. Combined with his medical history, physical examination, laboratory examinations with high C-reactive protein (CRP), platelet count (PLT), erythrocyte sedimentation rate (ESR) and fecal calprotectin levels, imaging examinations and pathology, a diagnosis of CD was taken into consideration. According to the pediatric CD activity index 47.5, methylprednisolone (40 mg QD) was given intravenously. The abdominal pain disappeared, and CRP, PLT, and ESR levels decreased significantly after the treatment. Unfortunately, he had a large amount of bloody stool again after 1 wk of methylprednisolone treatment, and his hemoglobin level decreased quickly. Although infliximab (IFX) (5 mg/kg) was given as a combination therapy regimen, he still had bloody stool with his hemoglobin level decreasing from 112 g/L to 80 g/L in a short time, so-called SLGIB. With informed consent, accelerated IFX (5 mg/kg) induction was given 7 days after initial presentation. The bleeding then stopped. Eight weeks after the treatment, repeat colonoscopy showed mucosal healing; thus far, no recurrent bleeding has occurred, and the patient is symptom-free.

CONCLUSION

This case highlights the importance of accelerated IFX induction in SLGIB secondary to CD, especially after steroid hormone treatment.

Diagnosis and treatment of Crohn's disease complicated by massive lower gastrointestinal hemorrhage

Crohn's Disease (CD) is a chronic granulomatous inflammatory disorder of the gastrointestinal tract. With the change of the life style and the progress of the diagnosis method, the number of patients diagnosed with CD has increased in China. In the course of disease development, some patients may have intestinal obstruction, abdominal abscess, acute perforation, gastrointestinal bleeding or other complications. Massive lower gastrointestinal hemorrhage is not a common complication of CD, and is a challenge for diagnosis and therapeutic management. It is more difficult to diagnose and treat CD associated lower digestive tract hemorrhage, compared with massive hemorrhage of lower digestive tract caused by other reasons. This paper reviews recent advances in the diagnosis and management of CD complicated with severe lower gastrointestinal hemorrhage.

[Basic mechanisms of hepatocellular injury. Role of inflammatory lipid mediators]

The presence of a lesion in the cellular parenchyma is common to a large number of chronic liver diseases, such as viral hepatitides, alcoholic hepatitis, chronic cholestasis and steatohepatitis. Although the pathogenesis may vary according to the etiological agent, a series of mechanisms is common to all. Notable among these mechanisms are Kupffer cell activation and inflammatory cell recruitment, free oxygen radical formation and the development of oxidative stress, cytokine production, mainly TNFa and TGFb, and inflammatory mediator release due to arachidonic acid oxidation through the COX-2 and 5-LO pathways.

Targeting T cell-specific costimulators and growth factors in a model of autoimmune hemolytic anemia

Although it is established that failure of regulatory mechanisms underlies many autoimmune diseases, the stimuli that activate autoreactive lymphocytes remain poorly understood. Defining these stimuli will lead to therapeutic strategies for autoimmune diseases. IL-2-deficient mice develop spontaneous autoimmunity, because of a deficiency of regulatory T cells, and on the BALB/c background, they rapidly die from autoimmune hemolytic anemia. To define the importance of costimulatory pathways in various components of this autoimmune disorder, we first intercrossed IL-2-deficient mice with mice lacking CD28 or CD40L. Elimination of CD28 reduced the activation of autoreactive T cells and lymphoproliferation as well as production of autoantibodies, whereas elimination of CD40L reduced autoantibody production without affecting T cell expansion and accumulation. To examine the role of IL-7, we blocked IL-7R signaling with neutralizing Abs. This treatment inhibited the production of autoantibodies and the development of autoimmune hemolytic anemia. Together, these data indicate that specific costimulatory and cytokine signals are critical for the spontaneous autoantibody-mediated disease that develops in IL-2-deficient mice.

Enterovesical Fistulas Secondary to Crohn's Disease: Medical versus Surgical Therapies

The purpose of this study is to evaluate the efficacy of medical therapies, especially infliximab, to induce remission of enteric fistulas in Crohn's disease (CD). Similarly to CD, chronic transmural inflammation of the bowel, diverticulitis and other pathologies may predispose to the development of fistulas. The risk of fistulization secondary to CD ranges from 17% to 80%. We focused on enterovesical fistulas, which statistically represent 10% of all fistulas secondary to CD.

Material and Methods

In this study we decided to implement a therapeutic program with infliximab 5 mg/kg associated with steroids, which proved to be the most effective method of treatment. From January 2003 to March 2005, we studied 4 patients with CD and enterovesical fistulas. All patients underwent NMR, colonoscopy and cystoscopy combined with fistulography; a therapeutic strategy with cortisone, mesalazine, nutritional therapy and infliximab was established.

Results

No regression was observed; therefore, all the four patients underwent surgery with complete remission of symptoms.

Conclusions

Data reported in literature and the evidence from our experience seem to be contradictory; we concluded therefore that it is mandatory to consider different therapeutic approaches, according to the fistulizing pathways, to such a complex disease, and to formulate some hypothesis that might explain why this treatment was unsuccessful in our patients.

Inhibitory effect of linomide on lipopolysaccharide-induced proinflammatory cytokine tumor necrosis factor-alpha production in RAW264.7 macrophages through suppression of NF-kappaB, p38, and JNK activation

Linomide is an immunomodulator that can effectively inhibit the development of several autoimmune diseases in animal models. Previously, linomide was shown to influence macrophage function, although the mechanism was elusive. In this study, we investigated the effect of linomide on the macrophage inflammatory cytokine, tumor necrosis factor-alpha (TNF-alpha), production induced by lipopolysaccharide (LPS) in vitro on the murine macrophage cell line, RAW264.7. Linomide exposure reduced LPS-evoked TNF-alpha production in a dose-dependent manner. Gel shift and reporter gene analyses revealed linomide inhibited LPS-induced NF-kappaB binding to the NF-kappaB consensus oligonucleotide and NF-kappaB-mediated reporter gene expression. Immunoblot analysis showed that linomide inhibited phosphorylation of p38 kinase and c-jun N terminal kinase (JNK) in LPS-stimulated RAW264.7 cells. Taken together, these results suggest that linomide inhibits TNF-alpha production by suppressing the activation of NF-kappaB and mitogen-activated protein kinase (MAPK), which might, at least in part, contribute to the beneficial effects of linomide in the treatment of autoimmune diseases.

Nasal septal perforation in an adolescent girl with Crohn's disease: a rare extraintestinal manifestation

Crohn's Disease (CD) is a chronic granulomatous inflammatory bowel disease which may also involve the extraintestinal organs such as joints, liver, skin and perianal tissue. Involvement of the aerodigestive tract is quite rare in CD. We report a 16-year-old girl with CD and nasal perforation as an extraintestinal manifestation of the disease.

Potential target of infliximab in autoimmune and inflammatory diseases

Tumour necrosis factor-alpha (TNF-alpha) is a pro-inflammatory cytokine produced by many cell types (blood monocytes, macrophages, mast cells and endothelial cells), that play a key role in the pathogenesis of multiple autoimmune and nonautoimmune disorders. A number of large placebo-controlled trials have shown that infliximab, a chimeric monoclonal antibody against TNF-alpha, is effective and well tolerated in patients with Crohn's disease, rheumatoid arthritis and spondiloarthritides and has become a widely used treatment for these diseases. Preliminary data suggest that several forms of vasculitis appear responsive to TNF antagonists: Behçet's disease, Churg-Strauss vasculitis, polyarteritis nodosa, and giant cell arteritis, among others. Wegener's granulomatosis and sarcoidosis have been shown to improve with infliximab. Polymyositis/dermatomyositis may also be responsive to TNF blockade. TNF likely plays little role in Sjögren's syndrome as evidenced by the lack of efficacy of TNF antagonists. There is a rationale for using TNF blockade even in systemic lupus erythematosus, a prototype of autoantibody-mediated disease, and a pilot study seems to confirm this potential effective approach. A number of other more rare disorders also may be responsive to TNF blockade. We here review the current and prospective roles of infliximab in the treatment of autoimmune diseases and other conditions.

Infliximab use in luminal Crohn's disease

Infliximab has been available in the United States and Europe for more than 6 years, and its use has revolutionized the care of patients who have CD. It is used effectively for both the induction and maintenance of remission in patients who have CD and is efficacious in patients who have steroid-dependent/refractory CD and those who have fistulizing CD. Clinical trials and practice have shown infliximab to be safe, effective, and generally well tolerated. The ACCENT I and ACCENT II trials defined the best dosing and schedule regimens for its administration. With up to 30% of patients not responding to infliximab therapy, much attention has been devoted to identifying risk factors that could allow optimization of response rates. Parsi and colleagues and Arnott and colleagues demonstrated that nonsmoking and the concurrent use of immunomodulators are predictors of response to infliximab. Research has also focused on identifying biologic and immunologic markers that may correlate with response to infliximab. To date, N0D2/CARD15, anti-Saccharomyces cerevisiae antibody (ASCA), and antineutrophil cytoplasmic antibody (ANCA) have not been shown to be predictive of outcome with infliximab treatment for CD. Gene polymorphisms also are being studies with the hope that knowing the patient's genotype may help predict the course or severity of the disease, including the presence of extraintestinal manifestations, response to treatments, and susceptibility to toxicities. No single variable, however, has been consistently demonstrated to be a predictor of response to infliximab. The formation of ATIs in a small number of patients creates a clinical dilemma. ATIs have been associated with an attenuated response or loss of response to the medication over time and the development of both acute and delayed infusion reactions that occasionally are severe enough to lead to discontinuation of the medication. In such patients physicians are often left to ponder what therapy to try next. Adalimumab, a fully human monoclonal antibody used for treating rheumatologic conditions, has been investigated as an alternate treatment for patients who have CD who, after initially responding to infliximab, experience intolerance or loss of efficacy. Two studies have examined the use of adalimumab in patients who have active CD who had lost response to or developed intolerance to infliximab. In both these studies adalimumab was well tolerated and seemed to be a clinically beneficial option for such patients. Confirmation of these findings with ongoing randomized, double-blind, placebo-controlled trials is needed, however. The limits of conventional treatment for CD can be seen as a positive evolutionary force favoring the development and use of advanced therapies. The acceptance of antimetabolites began with data published a quarter-century ago and became robust in the past 5 to 10 years. Biologic therapy has become the standard of care at a far faster rate. The success seen with infliximab has broadened the acceptance of biologic therapy among professional peers, patients, and pharmaceutical developers. The lessons learned in the years since infliximab's arrival show the importance of long-term data in revealing important toxicities and best practices for maintenance. Tempered by this experience, the short cycle from concept to drug production possible with biologic therapies should bring even more advanced treatments to patients quickly while investigators work to find a cure.

Infliximab: Use in Inflammatory Bowel Disease

Crohn's disease (CD) and ulcerative colitis (UC) are chronic and often debilitating inflammatory bowel diseases (IBD) without medical cures. Despite the existence of multiple therapies, the medical treatment of these diseases often has proven insufficient and surgery is frequently required. However, as our understanding of the pathogenesis of these disorders and other immune-mediated inflammatory diseases (eg, rheumatoid arthritis and psoriasis) has grown, new and more specific biologic therapies have been developed that are proving more effective than traditional agents. Infliximab is a genetically engineered monoclonal antibody that targets the proinflammatory cytokine tumor necrosis factor-alpha (TNF-alpha) and represents the first effective biologic therapy for IBD and has largely revolutionized treatment. Infliximab initially was developed to be used in patients with moderate to severe luminal or fistulizing CD who are refractory to standard medical therapy. More and more practitioners now are using infliximab as first-line therapy because of its superior efficacy. Infliximab rapidly induces remission in CD, but when given chronically, it can provide long-term maintenance of remission. In addition, there are some data to support its use as a steroid-sparing agent and treatment for various extraintestinal manifestations of IBD and, although used predominantly to treat CD, recent data suggest that infliximab also may have a role in the management of UC. Overall, infliximab represents a clinically useful, cost-effective therapy that works well, even though careful patient monitoring is required to avoid rare but significant toxicities. The hope is that infliximab, together with other biologic agents that currently are in development, will allow us to modify the course of IBD, avoid complications such as strictures and abscesses, and reduce the need for surgery.

Infliximab use in Crohn’s disease

Crohn's disease is a chronic inflammatory disease of the gastrointestinal tract. The disease can be quite severe, resulting in hospitalisation, requiring long-term treatment with a variety of medications and frequent surgeries. Infliximab is a chimeric monoclonal antibody directed against tumour necrosis factor, a key cytokine in the inflammatory cascade of many diseases, including Crohn's disease. Numerous studies have shown significant improvement in both clinical and endoscopic luminal and fistulising Crohn's disease with infliximab treatment. The clinical efficacy, indications, safety profile and future of infliximab are reviewed.

Medical Therapy of Crohn's Disease

There is no medical or surgical treatment that provides a permanent cure for Crohn's disease (CD). However, an evolving understanding of the pathogenesis of CD has provided clinicians with a diversity of medical treatment options for the disease. The goal of therapy is to induce and maintain clinical remission. The efficacy of immune-modifying agents such as azathioprine/6-mercaptopurine and infliximab have supported a paradigm shift in CD treatment in which maintenance agents are introduced earlier in the disease course. At the same time, it is imperative to balance the efficacy, safety, and tolerability of medical therapy. Given the variable and relapsing clinical course of CD, the physician and patient should ideally develop an ongoing relationship that allows for individualization of treatment regimens, monitoring of response and side effects, and modification of the therapeutic strategy in the absence of improvement.