These results show that if intravenous cyclosporine can induce remission, oral cyclosporine is not needed as a bridge to long term immunomodulatory therapy with azathioprine. This case illustrates that the clinical expectation for intravenous cyclosporine is complete induction of remission. Oral cyclosporine and infliximab may simply be prolonging the inevitable colectomy.
Another issue against a prolonged trial of medical therapy is the risk of colorectal cancer in CUC. After longstanding CUC, the risk of colonic dysplasia and cancer increases. It is estimated that after eight to 10 years of CUC, the incidence rate of colorectal cancer increases 0.5% to 1% per year. One can argue for earlier colectomy in this patient on the basis of the increasing cancer risk. Continue reading
There is little evidence to guide clinicians in the use of infliximab for patients who fail cyclosporine. Most of the evidence centres on steroid refractory disease. Probert et al studied the use of infliximab 5 mg/kg at week 0 and 2 versus placebo in steroid resistant ulcerative colitis. Twenty-two patients were randomly assigned to infliximab and 20 to the placebo group. After two and six weeks there was no statistical difference between the infliximab and placebo. Therefore, the use of infliximab in steroid refractory ulcerative colitis is of limited value. Patients with severe CUC refractory to intravenous steroids and intravenous cyclosporine should be viewed as having disease that requires surgical management. If studies of infliximab on steroid refractory CUC find only marginal response, it would be reasonable to suggest that disease resistant to both steroids and cyclosporine would not respond to infliximab. Continue reading
This is the first reported case of using infliximab as salvage medical therapy following failure of intravenous cyclosporine. The clinical situation and patient preference for continued medical therapy resulted in the trial of infliximab. The patient responded with rapid clinical improvement over 48 h but the response lasted only 10 days before she relapsed. A second infusion did not make a clinical difference. This case demonstrates that infliximab is not the best option for acute severe CUC that is refractory to cyclosporine. Continue reading
Intravenous cyclosporine was continued for 14 days. She felt well enough to be discharged from hospital. On discharge, she was having three small diarrheal stools and her abdominal pain improved. She was discharged on azathioprine 125 mg/day (2.5 mg/kg/day), cyclosporine (Neoral, Novartis Pharmaceuticals, USA) 175 mg (3.75 mg/kg/day) and budes-onide enemas. She was required to have weekly complete blood counts and cyclosporine C0 levels. Continue reading
A 24 year-old white woman with CUC presented with a five-day history of more than 12 large volume bloody diarrhea per day. She had crampy left lower quadrant abdominal pain and worsening fatigue over the preceding two weeks. There was no antecedent upper respiratory tract infection, nonsteroidal antiinflammatory medications or antibiotic use. She had significant tenesmus. There was no fever or chills. There were no extraintestinal manifestations of inflammatory bowel disease. Continue reading
Intravenous corticosteroids remain the initial therapy for a severe acute flare of chronic ulcerative colitis (CUC). Therapeutic options for patients who have failed a trial of steroids depend on the clinical scenario and, in part, patient preference. Although colectomy is curative, patients who are not presenting with acute abdominal symptoms requiring surgery may elect to have a trial of medical therapy. Intravenous cyclosporine has been used to induce remission in patients with steroid refractory acute flares. Approximately 18% to 43% of these patients fail to respond to cyclosporine and total proctocolectomy is the only therapeutic option. Continue reading