USE OF INFLIXIMAB, PEGYLATED INTERFERON AND RIBAVIRIN IN A PATIENT WITH CROHNʼS DISEASE AND HEPATITIS C INFECTION

Abstract

Infliximab (antibody to TNF-alpha) that has been demonstrated to cause and maintain remission in patients with fistulizing Crohn's disease (CD). Because there is evidence for a role of TNF signalling in viral hepatitis and extreme paucity of data on the effect of infliximab on hepatitis C virus (HCV), cautious use of anti-TNF antibodies in these conditions has been recommended. Due to possible increase in the incidence of HCV in this group of patients due to surgical procedures, these concerns represent a potential drawback in effective management of CD. Here we report a case with CD and HCV who received Infliximab and Pegylated interferon (PEG-IFN) respectively. Case: This is a 39-year-old white female with history of CD since 1985 status post ileocolonic resection 15 years ago with perianal/fistulizing disease presently. She developed HCV (genotype 1a) as a result of blood transfusions at the time of the surgery. Her liver biopsy in March 2002 showed Grade 3 inflammation with stage 2 fibrosis. The quantitative HCV-PCR was 1.2 million copies with an ALT of 75 and AST 55 (mildly elevated). The rest of her liver tests (LFTs) including coagulation profile were normal. The plan was to start treatment with Interferon for chronic HCV after inducing remission of CD. Therapy with Infliximab was initiated in April 2002 with complete closure of fistulas. Patient received initial infusions at 0, 2, 6 weeks and every 8 weeks thereafter for maintenance. LFTs were monitored every 30 days during therapy. It was noted that patient's transam-inases normalized during infliximab therapy. Repeat quantitative HCV-PCR was1.5 million copies. Due to persistent elevation in viral loads, the decision was made to start anti-viral treatment. Treatment with PEG-IFN and Ribivarin was started in June 2003. Patient completed 48 weeks of therapy with undetectable viremia and no excerbation of CD during anti-viral therapy. Conclusions: Alpha-TNF levels are increased in patients with HCV and inhibition of these levels could lead to a selective advantage to HCV replication due to evasion of host antiviral defence mechanisms leading to accelerated progression of hepatic decompensation. But the above case depicts no change/progression in the liver disease upon treatment with infliximab and furthermore, once the CD is in remission, treatment with IFN does not appear to worsen the symptoms.