A Crohn's Disease Patient Who Does Not Respond to Infliximab: What Is Next?

Abstract

Clinical Scenario A nonsmoking woman with a history of Crohn’s disease (CD) for 22 years presents with abdominal pain nd diarrhea. Her course was characterized by chronic mild ymptoms interspersed with significant symptomatic flares ith bloody diarrhea, abdominal pain, and weight loss reuiring corticosteroids approximately 3 times yearly. She ould respond to prednisone, and when tapered, she was mainained on mesalamine with intermittent courses of metronidaole for milder symptoms. Eight years earlier, 6-mercaptopurine as added, but she developed pancreatitis. Endoscopically, she as had documented segmental inflammatory involvement of he rectum, ascending colon, and cecum. Eighteen months arlier she experienced a significant disease exacerbation. tool cultures and Clostridium difficile toxin A and B assays ere negative. Computed tomography enterography demontrated segmental involvement of the colon without involveent of the small bowel. Colonoscopy and biopsies demontrated segmental moderate to severely active colonic CD ith deep ulcerations. Infliximab was initiated at 5 mg/kg ntravenously with induction at weeks 0, 2 and 6, followed by very 8-week maintenance. She was in clinical remission for months. During the past 5 months, she became symptomtic increasingly earlier between infliximab infusions. Three onths ago when she was significantly symptomatic 4 weeks fter the previous infusion, the infliximab dose was increased o 10 mg/kg. However, when first presenting to our office, he had received infliximab 2 weeks prior and had not sympomatically improved. She is currently having 6 bowel moveents daily, 1 nocturnal bowel movement, most of which ontain blood. She has significant lower quadrant abdominal ain and has lost 10 pounds during the past 4 months. aboratory evaluation is remarkable for hemoglobin of 10.8 /dL, platelets 566,000 106/L, C-reactive protein (CRP) 32 g/dL, and albumin 3.4 g/dL.