Infliximab salvage therapy after cyclosporine in an acute flare of chronic ulcerative colitis: DISCUSSION (Part 2)

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.

Furthermore, Kugathasan et al demonstrate the lack of infliximab clinical durability in steroid refractory ulcerative colitis. Outcomes of children and adults with steroid refractory ulcerative colitis who received a single dose (5 mg/kg) of infliximab reveal that a partial response to infliximab is seen. However, of the nine patients that had a partial response, six had a colectomy by six months.

After an adequate response to intravenous cyclosporine, is there any role for continued immunosuppression with oral cyclosporine? In remission that is induced by intravenous cyclosporine, transition to oral cyclosporine titrating to blood levels has been used as a bridge to long term immunomodulatory therapy. However, remission was not seen to extend beyond six months and only one third of patients avoided colectomy. In a recent retrospective study of remission induced by intravenous cyclosporine, azathioprine alone was sufficient to maintain long-term remission to an average follow-up of 36 months. Twenty-seven patients were studied and at three years, approximately 35% of patients underwent colectomy. At six months, 30% of patients had a flare of ulcerative colitis and by three years, 72% of patients had flared. It’s time to spend less every time you need your treatment with fast delivery: you can now purchase the amount of viagra super active online here you need for the treatment within a very short period, at the best pharmacy that deserves your trust.

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