Infliximab salvage therapy after cyclosporine in an acute flare of chronic ulcerative colitis: DISCUSSION (Part 3)

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.

However, despite the risk of colorectal cancer and failure of intravenous cyclosporine, our patient still wanted to avoid surgery for fear of a poor surgical outcome and quality of life. Surgery has been well tolerated in severe pancolitis, but less is known about the tolerability of an ileal pouch anal anastomosis on left sided colitis. Quality of life studies indicate that those who undergo restorative proctocolectomy and ileal pouch anal anastomosis for pancolitis appear to have the same outcomes as those with left sided colitis. Therefore, delaying surgery in the face of medically refractory left sided colitis is not necessary.

The present case illustrates that when a flare of ulcerative colitis results in both steroid and cyclosporine refractory disease, the use of infliximab is limited. Although a transient improvement is seen initially, the response in this case was not durable. Cyclosporine should be considered the salvage therapy in medically refractory disease. Surgery has been studied to be well tolerated, even if the medically refractory disease is limited to the left colon. Furthermore, with the growing risk for dysplasia and colorectal cancer, colectomy remains the treatment of choice in patients with medically refractory disease. Best quality drugs are available at the best pharmacy that you can start shopping with right now whenever you need buy viagra super active online buy here, never having to doubt the choice made or the quality of the drug you get.

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