Original article—alimentary tract
Cyclosporine and Infliximab as Rescue Therapy for Each Other in Patients With Steroid-Refractory Ulcerative Colitis

https://doi.org/10.1016/j.cgh.2008.04.035Get rights and content

Background & Aims

In patients with severe corticosteroid-refractory ulcerative colitis, cyclosporine or infliximab may be added in an effort to induce remission. If the patient then fails either of these drugs, it is unknown whether success can be achieved by using the other agent. The aim of this study was to assess outcomes of using cyclosporine after failure of infliximab, and vice versa.

Methods

We retrospectively reviewed the charts of 19 patients with corticosteroid-refractory ulcerative colitis who received either infliximab after failed cyclosporine or cyclosporine after failed infliximab. Acute salvage therapy was defined as having received the alternate drug within 4 weeks of discontinuing the first agent.

Results

Ten patients received infliximab after failing cyclosporine; 9 patients received cyclosporine after failing infliximab. Four patients (40%) in the infliximab-salvage group achieved remission, as did 3 (33%) in the cyclosporine-salvage group. Remission lasted a mean of 10.4 months (range, 4.4–17.03 mo) and 28.5 months (range, 5.0–41.5 mo), respectively. Severe adverse events included one patient who developed sepsis and died after receiving infliximab salvage. One patient who received cyclosporine salvage developed herpetic esophagitis, and another patient who received cyclosporine salvage developed pancreatitis and bacteremia.

Conclusions

In patients with severe corticosteroid-refractory ulcerative colitis who fail treatment with either cyclosporine or infliximab, remission rates using acute salvage therapy by crossing over to the other drug occur in approximately one third of patients and have limited duration. Serious adverse events occurred in 16%, including 1 death, suggesting that the risks of acute salvage therapy may outweigh the benefits.

Section snippets

Patients

We retrospectively reviewed the records of patients with severe UC who had failed either intravenous steroids at a dose equivalent to at least 60 mg/d of prednisone, or patients who had failed at least one course of oral prednisone at a minimum dose of 40 mg/d for 2 weeks. We identified those patients who received cyclosporine first and then infliximab as acute salvage therapy (IFX-salvage), or who failed infliximab first and then received cyclosporine as acute salvage therapy (CSA-salvage).

Patient Demographics

Nineteen patients, 9 men and 10 women, underwent acute salvage therapy with either cyclosporine or infliximab within 4 weeks of discontinuing the other. Demographic data are shown in Table 2. Ten patients who failed cyclosporine were treated with infliximab as acute salvage therapy (IFX-salvage group), 9 patients who failed infliximab received cyclosporine as acute salvage therapy (CSA-salvage group). In all patients, the reason for switching to cyclosporine or infliximab was failure to achieve

Discussion

Patients with severe ulcerative colitis who fail high-dose corticosteroids have limited medical options to achieve remission and avoid colectomy. Patients often are referred to our center because they are reluctant to undergo colectomy and are seeking additional medical therapy. This is primarily owing to known complications of J-pouch surgery, including frequent bowel movements, incontinence, decreased fecundity, and others.13

We found that in patients who failed to achieve remission with

References (16)

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E.A.M., D.D., and D.H.P. have no conflicts of interest to disclose; S.L. received research grants from Centocor (not for this project); T.U. received speaking and consulting fees from Abbott, Centocor, and UCB Pharmaceuticals; and A.K. received advisory board and speaking fees from Abbott, Centocor, and UCB Pharmaceuticals. Potential investigator conflicts of interest were not disclosed to subjects (study participants); they were disclosed to all authors involved.

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