Clinical Utility of Infliximab in Treating Acute Exacerbation of Crohnʼs Disease in the Treatment Naïve Patients

Abstract

Purpose: Anti-tumour necrosis factor-alpha (TNF-a) agents have revolutionized the clinical management of inflammatory bowel diseases (IBD) refractory to conventional medications (corticosteroids, immunomodulators). Anti-TNF-a agents such as infliximab, adalimumab, and certolizumab have been found are more effective than placebo for the induction and maintenance of remission in luminal Crohn's disease. Among the three agents, infliximab is the only one approved by Food and Drug Administration (FDA) for the outpatient management of ulcerative colitis and both infliximab and adalimumab have been found effective in maintenance of fistula closure in Crohn's disease. However, the available level of evidence is D for the use of infliximab in severely ill patients hospitalized for an acute exacerbation of Crohn's disease and its role remains unknown for inpatient management of ulcerative colitis. Therefore, we investigated the clinical response of infliximab in IBD patients hospitalized for acute flare-up. Methods: We conducted a retrospective review of the electronic medical records (EMR) of all patients at our institution admitted with diagnosis of acute flare-up of ulcerative or crohn's disease and who then underwent inpatient management with infliximab between January 2007-September 2009. Factors reviewed included: age, race, sex, duration of symptom onset, extent/location of disease, presence of co-morbid conditions, use of tobacco/alcohol, and concomitant/past use of immunosuppressants. Clinical response was defined as relief/resolution of symptoms resulting in early discharge and outpatient follow-up 6-8 weeks later for next treatment dose. Non-responders were identified by prolonged length of hospital stay and/or if patient required surgery. Results: EMR review of over 2000 patient found that 47 patients met the inclusion criteria of which 24 had Crohn's disease and 23 had ulcerative colitis. Infliximab treatment found 22 responders in the Crohn's disease of which 32% had fistulizing disease, 44% had ileal involvement and 24% had segmental disease. Analysis of data from ulcerative colitis patients revealed 17 responders with smoking (OR 7.14) and prior use of immunosuppressants (OR 3.25) as positive predictors of infliximab failure. Conclusion: Our study supports the use of infliximab as a preferred treatment over steroids in patients hospitalized with an acute flare-up of crohn's disease without any previous exposure to anti-TNF-a agents. These results demonstrate morbidity benefit in patients with Crohn's disease with shortened duration of stay in hospital and better treatment response for whom few therapeutic options are available.