Long-term management of resistant, fistulazing Crohn's disease by ongoing 4-weekly infliximab therapy (a case report)

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Abstract
Background: Management of fistulizing Crohn's disease has been revolutionized by anti-TNF biologics. Scheduled ongoing anti-TNF therapy for maintenance, with a recommended frequency of 8 weeks has been established by the ACCENT-I trial and subsequent analyses (eg. Gastroenterology,126:402–413). However, almost two third of patients remain symptomatic. Our Patient: is a 20 year-old male subject with a 3 years' history of fistulizing Crohn's Disease. Because of resistance to standard immunosuppressive medications (steroids & azathioprine (AZA) in addition to 5ASA), he received the first 3 cycles of infliximab in May-Jun 2003. At that time steroid-induced osteoporosis was already present. After full initial response and tapered steroids, the fistula opened subsequent to a follicular tonsillitis in Oct 2003. In order to achieve long term remission, scheduled 8-weekly treatment regime was started with 5mg/bw of infliximab, while 2mg/bw of AZA was continued. Complete remission, however was never lasting for more 5 weeks until Jul 2004 with 5 cycles completed. Relapses were characterized by elevated ESR & CRP, loss of appetite and vomiting. Within 1–2 weeks time he had lost 5–8kgs and reached BMI 19. Osteoporosis was not improving despite the 4 weeks intervals of remission. Because of failure to achieve sustained remission, we switched to 4 weekly infliximab (5mg/bw) along with bolus 40mg of methylprednisone and continuing AZA (2mg/bw). Ever since, both CRP & ESR levels are consistently normal and the patient is off steroids. So far, he had not experienced side effects of infliximab. The patient has no clinical symptoms and lives the normal life of a young adult for more than 6 months now. Discussion: In case sustained remission cannot be achieved by 8 weekly scheduled infliximab therapy, more frequent application can be a safe option in responsive patients. According to registration data (www.fda.gov), Infliximab infusion 5mg/bw has a mean residence time in human plasma of 286h with a half life of 187h. Based on these facts, 4 weekly administration of anti-TNF therapy seems a reasonable option for the carefully selected, responsive patient in a tertiary referral center.

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