Accelerated induction regimens of TNF-alpha inhibitors in patients with inflammatory bowel disease: a scoping review protocol

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.

Is There a Role for Therapeutic Drug Monitoring in Patients with Hidradenitis Suppurativa on Tumor Necrosis Factor-α Inhibitors?

Tumor necrosis factor-α inhibitors, adalimumab and infliximab, are at the forefront of biologic therapy for the management of moderate-to-severe hidradenitis suppurativa, with adalimumab as currently the only approved medication for this condition. In treating patients, primary or secondary lack of response (also termed suboptimal response) is a major burden for both patients and healthcare systems and is a challenge with biologics in part owing to the development of anti-drug antibodies following treatment. To overcome this, therapeutic drug monitoring may be conducted proactively or reactively to a patient's suboptimal response guided by measurements of trough serum drug concentrations and levels of anti-drug antibodies. While strong evidence to support the utility of therapeutic drug monitoring exists in patients with inflammatory bowel disease, current information is limited in the context of hidradenitis suppurativa. We sought to summarize the available evidence and to present the role of therapeutic drug monitoring and other dose optimization strategies in improving clinical response in patients with hidradenitis suppurativa treated with tumor necrosis factor-α inhibitors.