Severe Corticosteroid-Refractory Ulcerative Colitis Successfully Treated with Serial High-Dose Infliximab During Hospitalization

Abstract

Patients with severe Ulcerative Colitis (UC) whom fail to respond to intravenous (IV) corticosteroids have successfully been treated with infliximab as a rescue therapy to avoid colectomy. There are limited reports of patients requiring multiple infliximab induction while hospitalized. Our institutional protocol is to re-dose patients after 3-5 days if there is partial or no response to the initial dose of infliximab. We report a prospective case series of 4 patients admitted to Indiana University Hospital in 2015-16 with severe UC requiring multiple doses of infliximab to achieve clinical remission. Patients with severe colitis (Mayo Score >9) and were refractory to 5 days of IV steroids. All patients had sigmoidoscopy prior to infliximab with biopsies for CMV immunohistochemistry (IHC) and stool tested for clostridium difficile. Treatment with an induction dose of 10mg/kg infliximab with monitoring of clinical symptoms and CRP. Those that demonstrated limited or no clinical response after 3-5 days were given a second induction dose of infliximab 10mg/kg. Patients were evaluated with partial Mayo scores. Assessed 90 day colectomy rates. Four patients average age 21 years (range 18-25, 3 males and 1 female) with UC with average baseline Mayo score of 10.75 were treated with two doses of infliximab 10 mg/kg and one patient received a third dose. All patients had severe colitis on sigmoidoscopy. Biopsies were all negative for CMV IHC. Average peak CRP was 14.8 and significantly improved at discharge 4.75 (p = 0.016). Initial average partial Mayo Score was 7.75 significantly improved at discharge 1.25 (p = 0.001). CRP collected 2 months after discharge in three patients normalized. Three patients maintained clinical remission at mean follow-up 8 months after hospitalization with partial Mayo Score mean of 1. One patient experienced recurrence of severe colitis at 11 months. No patients had an adverse event. No patients had colectomy at the 90 follow-up. Our case series demonstrates the safety and efficacy of serial high dose infliximab infusions in treating patients with severe corticosteroid-refractory UC who had a poor response to the initial dose of infliximab. Sustained clinical remission was noted in 3/4 patients. One patient relapsed. None required colectomy at 90 days. Larger studies are needed to evaluate the safety and efficacy of consecutive high dose infliximab in patients with severe UC.Figure 1Figure 2