Treatment of acute severe ulcerative colitis using accelerated infliximab regimen based on infliximab trough level: A case report

Abstract

BACKGROUND Acute severe ulcerative colitis (ASUC) is a complication of ulcerative colitis associated with high levels of circulating tumor necrosis factor alpha, due to the intense inflammation and faster stool clearance of anti-tumor necrosis factor drugs. Dose-intensified infliximab treatment can be beneficial and is associated with lower rates of colectomy. The aim of the study was to present a case of a patient with ASUC and megacolon, treated with hydrocortisone and accelerated scheme of infliximab that was monitored by drug trough level. CASE SUMMARY A 22-year-old female patient diagnosed with ulcerative colitis, presented with diarrhea, rectal bleeding, abdominal pain, vomiting, and distended abdomen. During investigation, a positive toxin for Clostridium difficile and colonic dilatation of 7 cm consistent with megacolon were observed. She was treated with oral vancomycin for pseudomembranous colitis and intravenous hydrocortisone for severe colitis, which led to the resolution of megacolon. Due to the persistent severe colitis symptoms, infliximab 5 mg/kg was prescribed, monitored by drug trough level (8.8 μg/mL) and fecal calprotectin of 921 μg/g (< 30 μg/g). Based on the low infliximab trough level after one week from the first infliximab dose, the patient received a second infusion at week 1, consistent with the accelerated regimen (infusions at weeks 0, 1, 2 and 6). We achieved a positive clinical and endoscopic response after 6 mo of therapy, without the need for a colectomy. CONCLUSION Infliximab accelerated infusions can be beneficial in ASUC unresponsive to the treatment with intravenous corticosteroids. Longitudinal studies are necessary to define the best therapeutic drug monitoring and treatment regimen for these patients.

Total Proctocolectomy Resulting from Toxic Megacolon in A Young Patient with Ulcerative Rectocolitis: Systematic Review and Case Report

“…Table 1: Compares the reports found in the literature [3][4][5][6][7][8][9]. These are studies with 1 or more patients described, comparing them based on common factors, such as gender, age at onset of symptoms, clinic and treatment, as well as prognosis.…”

Colonic Dilatation Complicating Acute Severe Ulcerative Colitis Managed Successfully with Accelerated Infliximab Dosing

“…High CRP/albumin ratio, like in our case, is a predictor of high-risk patients who will benefit from the accelerated regimen [22] . In addition, therapeutic drug monitoring may aid in choosing the most suitable candidate for this strategy as reported by Garate et al [12] .…”

“…Tacrolimus demonstrated effectiveness in both cases, although ganciclovir was added in one case because of CMV detection. Recently, Garate et al [12] presented a case of ASUC complicated by Clostridium difficile -related megacolon. The dilatation of the transverse colon was rapidly resolved with oral vancomycin and intravenous steroids, but the hematochezia did not improve.…”

“…In real-world evidence, there are eight cases of secukinumab-related ulcerative colitis that have been described from 2018 to 2021 [4][5][6][7][8][9][10]. In terms of acute severe ulcerative colitis (ASUC) complications, megacolon without toxicity has not been well characterized with only 3 case reports [11,12]. These cases, however, had colonic dilatation of less than 10 cm.…”