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Infliximab in the treatment of IBD-associated psoriasis and psoriasis-associated IBD
S266
Abstracts
809 ASYMPTOMATIC CROHN’S DISEASE DETECTED BY SCREENING COLONOSCOPY Miriam R. Thomas, M.D, Jay Levinson, M.D* and Philip Goldmeier, M.D. Gastroenterology, Providence Hospital, Southfield, MI. Purpose: Crohn’s disease encompasses a spectrum of clinical and pathological patterns. The heterogeneity of manifestations, a potentially insidious onset and/or presentation without GI symptoms can make the diagnosis of Crohn’s disease difficult. Studies that are based on symptomatic inpatients diagnosed may underestimate the true prevalence of inflammatory bowel disease by 27–38%. As screening colonoscopy has gained wider acceptance, we have detected Crohn’s disease in a number of asymptomatic or minimally symptomatic individuals. Case #1: A 62 year– old man presented for screening colonoscopy. He denied any gastrointestinal symptoms and past medical history was not significant. Family history was negative for colon cancer or IBD. Physical examination was unremarkable. Colonoscopy revealed a 4 cm ulcerating lesion in the hepatic flexure raising concern for malignancy. Initial biopsies revealed “focal active inflammation with architectural distortion”. Repeat colonoscopy within 2 weeks demonstrated “chronic colitis with deep submucosal granulomas”. Immunohistochemical stain for mycobacterium was negative. Small bowel series showed terminal ileitis consistent with Crohn’s disease. Laboratory data were normal. Case #2: A 61 year– old female underwent a routine screening colonoscopy, which showed friability, granularity and small ulcerations of the terminal ileum with a mild stricture. He was asymptomatic. There was no family history of IBD. Physical examination was unremarkable. There was no abdominal mass or tenderness. Laboratory data were normal. Ileal biopsies revealed “ chronic active inflammation and fragments of granulation tissue consistent with an ulcer.” Small bowel series revealed abnormal configuration of the terminal ileum and ileocecal valve with narrowing and loss of mucosal pattern of the distal 7 cm of the ileum. Conclusions: Our cases demonstrate that symptoms may be absent even in the presence of significant inflammation. Even upon specific retrospective questioning, these patients denied symptoms of inflammatory bowel disease. This highlights concern about the accuracy and completeness of case detection of inflammatory bowel disease. The discrepancy between endoscopic findings and symptoms often poses a dilemma for the clinician even in well– established cases. Controversies raised include the appropriateness of active medical therapy vs. watchful waiting in asymptomatic cases detected serendipitously by colonoscopy.
810 INFLIXIMAB IN THE TREATMENT OF IBD–ASSOCIATED PSORIASIS AND PSORIASIS–ASSOCIATED IBD Mark R. Fleisher, M.D.*, Steven D. Rubin, M.D., Andrew E. Levine, M.D. and Alexander W.R. Burns, M.D. Borland–Groover Clinic, Jacksonville, FL; Long Island Gastroenterology Group, Merrick, Long Island, NY and New South Wales, Sydney, Australia. Purpose: IBD is a spectrum of illness ranging from Crohns disease to ulcerative colitis. Aside from the overt gastrointestinal consequences, there are numerous extraintestinal manifestations (EIMs) of almost every organ system. The most common and commonly recognized dermatologic manifestations include erythema nodosum, pyderma gangrenosum, acute leucocytoclastic vasculitis and granuloma annulare. Psoriasis is an autoimmune disease in which cytokines are thought to stimulate the development of the altered keratinocyte phenotype. Moreover, TNF–alpha may play a role in the induction and maintenance of psoriasis. We describe five patients treated with infliximab for both IBD and psoriasis simultaneously. Methods: Three patients with IBD (2 Crohns and 1 pancolitis) flared despite mesalamine. During their increased IBD activity, psoriatic lesions
AJG – Vol. 97, No. 9, Suppl., 2002
developed on their elbows and knees. Two patients with longstanding psoriasis developed diarrhea and evaluation revealed that each had overt ileitis. All five developed arthritis. Each was treated with infliximab (5mg/ kg) at 0/2 and 6 weeks and every 8 weeks thereafter. Results: Each of the five patients were able to achieve gastrointestinal, rheumatologic and dermatologic remission. The psoriasis resolved in all five cases within two weeks of the initial infusion. Arthritis resoved in each patient by the 5th week. Gastrointestinal remission was reached clinically in each patient by week 9. After 55 weeks, all the patients are still in gastointestinal, rheumatologic and dermatologic remission. None have required steroid therapy. Conclusions: In the ven diagram of medicine, there is a burgeoning fund of knowledge leading us to believe that seemingly unrelated illnesses are indeed kin. Not merely do symptoms overlap but therapies, as well. The efficacy of infliximab in gastroenterology, dermatology and rheumatology is rooted in a seemingly common pathway of autoimmunogenicity. Whether psoriasis is an EIM of IBD or IBD is an extradermatologic manifestation (EDM) of psoriasis is moot. Their treatments are the same, need to be initiated early and maintained indefinitely.
811 STEROIDS VS. INFLIXIMAB IN THE TREATMENT OF CROHN’S DISEASE: A TWO YEAR PROSPECTIVE EXPERIENCE Mark R. Fleisher, M.D.*, Steven D. Rubin, M.D., Andrew E. Levine, M.D. and Alexander W.R. Burns, M.D. Borland–Groover Clinic, Jacksonville, FL; Long Island Gastroenterology Group, Merrick, Long Island, NY and New South Wales, Sydney, Australia. Purpose: Crohns Disease is one end of the spectrum of Inflammatory Bowel Disease. It is often difficult to diagnose due to its multiplicity and vagueries of guises. Once uncovered, it is still a frightening entitiy for the patient and a daunting foe for the clinician. This may be a consequence of the numerous medications available but unclear algorithm regarding their applications. By monitoring our Crohns patients for two years, we seek to assist in answering these questions. Methods: In our practices, we treated and subsequently monitored 120 Crohns patients with active disease despite mesalamine and antibiotic therapy. One group received prednisone (40mg PO qD for 4 weeks and tapered 5mg every two weeks). The second group received infliximab (5mg/kg; 0/2 and 6 weeks). The last group received infliximab (5mg/kg; 0/2 and 6 weeks and every 8 weeks thereafter).These patients were divided into two two divisions: steroid– naive and steroid–veterans. Their progress was monitored over two years. Results: The following results were noted: Able to achieve clinical remission by week 7: a) prednisone: 95% (steroid naive), 55% (steroid veterans) b) triple dose infliximab: 85%(steroid naive), 65%(steroid veterans) c) continual infliximab: 80% (steroid naive), 65% ( steroid veterans) Able to maintain remission by week 52: a) prednisone: 15% (steroid naive), 5% (steroid veterans) b)triple dose infliximab: 35% (steroid naive), 15% (steroid veterans) c) continual infliximab: 75% (steroid naive), 55% (steroid veterans) Able to maintain remission by week 104: a) prednisone: 10% (steroid naive), 0% (steroid veterans) b) triple dose infliximab: 15% (steroid naive), 5% (steroid veterans) c) continual infliximab: 70% (steroid naive), 45% (steroid veterans) Conclusions: The treatment algorithm for Crohns Disease is evolving. Our findings support earlier application and continuation of infliximab in order to induce and maintain remission. The axiom “a lifelong illness requires lifelong therapy” leads to the corollary “a lifelong illness does not imply lifelong sickness.” These tenets need to be applied with constant vigilence.
Abstracts
809 ASYMPTOMATIC CROHN’S DISEASE DETECTED BY SCREENING COLONOSCOPY Miriam R. Thomas, M.D, Jay Levinson, M.D* and Philip Goldmeier, M.D. Gastroenterology, Providence Hospital, Southfield, MI. Purpose: Crohn’s disease encompasses a spectrum of clinical and pathological patterns. The heterogeneity of manifestations, a potentially insidious onset and/or presentation without GI symptoms can make the diagnosis of Crohn’s disease difficult. Studies that are based on symptomatic inpatients diagnosed may underestimate the true prevalence of inflammatory bowel disease by 27–38%. As screening colonoscopy has gained wider acceptance, we have detected Crohn’s disease in a number of asymptomatic or minimally symptomatic individuals. Case #1: A 62 year– old man presented for screening colonoscopy. He denied any gastrointestinal symptoms and past medical history was not significant. Family history was negative for colon cancer or IBD. Physical examination was unremarkable. Colonoscopy revealed a 4 cm ulcerating lesion in the hepatic flexure raising concern for malignancy. Initial biopsies revealed “focal active inflammation with architectural distortion”. Repeat colonoscopy within 2 weeks demonstrated “chronic colitis with deep submucosal granulomas”. Immunohistochemical stain for mycobacterium was negative. Small bowel series showed terminal ileitis consistent with Crohn’s disease. Laboratory data were normal. Case #2: A 61 year– old female underwent a routine screening colonoscopy, which showed friability, granularity and small ulcerations of the terminal ileum with a mild stricture. He was asymptomatic. There was no family history of IBD. Physical examination was unremarkable. There was no abdominal mass or tenderness. Laboratory data were normal. Ileal biopsies revealed “ chronic active inflammation and fragments of granulation tissue consistent with an ulcer.” Small bowel series revealed abnormal configuration of the terminal ileum and ileocecal valve with narrowing and loss of mucosal pattern of the distal 7 cm of the ileum. Conclusions: Our cases demonstrate that symptoms may be absent even in the presence of significant inflammation. Even upon specific retrospective questioning, these patients denied symptoms of inflammatory bowel disease. This highlights concern about the accuracy and completeness of case detection of inflammatory bowel disease. The discrepancy between endoscopic findings and symptoms often poses a dilemma for the clinician even in well– established cases. Controversies raised include the appropriateness of active medical therapy vs. watchful waiting in asymptomatic cases detected serendipitously by colonoscopy.
810 INFLIXIMAB IN THE TREATMENT OF IBD–ASSOCIATED PSORIASIS AND PSORIASIS–ASSOCIATED IBD Mark R. Fleisher, M.D.*, Steven D. Rubin, M.D., Andrew E. Levine, M.D. and Alexander W.R. Burns, M.D. Borland–Groover Clinic, Jacksonville, FL; Long Island Gastroenterology Group, Merrick, Long Island, NY and New South Wales, Sydney, Australia. Purpose: IBD is a spectrum of illness ranging from Crohns disease to ulcerative colitis. Aside from the overt gastrointestinal consequences, there are numerous extraintestinal manifestations (EIMs) of almost every organ system. The most common and commonly recognized dermatologic manifestations include erythema nodosum, pyderma gangrenosum, acute leucocytoclastic vasculitis and granuloma annulare. Psoriasis is an autoimmune disease in which cytokines are thought to stimulate the development of the altered keratinocyte phenotype. Moreover, TNF–alpha may play a role in the induction and maintenance of psoriasis. We describe five patients treated with infliximab for both IBD and psoriasis simultaneously. Methods: Three patients with IBD (2 Crohns and 1 pancolitis) flared despite mesalamine. During their increased IBD activity, psoriatic lesions
AJG – Vol. 97, No. 9, Suppl., 2002
developed on their elbows and knees. Two patients with longstanding psoriasis developed diarrhea and evaluation revealed that each had overt ileitis. All five developed arthritis. Each was treated with infliximab (5mg/ kg) at 0/2 and 6 weeks and every 8 weeks thereafter. Results: Each of the five patients were able to achieve gastrointestinal, rheumatologic and dermatologic remission. The psoriasis resolved in all five cases within two weeks of the initial infusion. Arthritis resoved in each patient by the 5th week. Gastrointestinal remission was reached clinically in each patient by week 9. After 55 weeks, all the patients are still in gastointestinal, rheumatologic and dermatologic remission. None have required steroid therapy. Conclusions: In the ven diagram of medicine, there is a burgeoning fund of knowledge leading us to believe that seemingly unrelated illnesses are indeed kin. Not merely do symptoms overlap but therapies, as well. The efficacy of infliximab in gastroenterology, dermatology and rheumatology is rooted in a seemingly common pathway of autoimmunogenicity. Whether psoriasis is an EIM of IBD or IBD is an extradermatologic manifestation (EDM) of psoriasis is moot. Their treatments are the same, need to be initiated early and maintained indefinitely.
811 STEROIDS VS. INFLIXIMAB IN THE TREATMENT OF CROHN’S DISEASE: A TWO YEAR PROSPECTIVE EXPERIENCE Mark R. Fleisher, M.D.*, Steven D. Rubin, M.D., Andrew E. Levine, M.D. and Alexander W.R. Burns, M.D. Borland–Groover Clinic, Jacksonville, FL; Long Island Gastroenterology Group, Merrick, Long Island, NY and New South Wales, Sydney, Australia. Purpose: Crohns Disease is one end of the spectrum of Inflammatory Bowel Disease. It is often difficult to diagnose due to its multiplicity and vagueries of guises. Once uncovered, it is still a frightening entitiy for the patient and a daunting foe for the clinician. This may be a consequence of the numerous medications available but unclear algorithm regarding their applications. By monitoring our Crohns patients for two years, we seek to assist in answering these questions. Methods: In our practices, we treated and subsequently monitored 120 Crohns patients with active disease despite mesalamine and antibiotic therapy. One group received prednisone (40mg PO qD for 4 weeks and tapered 5mg every two weeks). The second group received infliximab (5mg/kg; 0/2 and 6 weeks). The last group received infliximab (5mg/kg; 0/2 and 6 weeks and every 8 weeks thereafter).These patients were divided into two two divisions: steroid– naive and steroid–veterans. Their progress was monitored over two years. Results: The following results were noted: Able to achieve clinical remission by week 7: a) prednisone: 95% (steroid naive), 55% (steroid veterans) b) triple dose infliximab: 85%(steroid naive), 65%(steroid veterans) c) continual infliximab: 80% (steroid naive), 65% ( steroid veterans) Able to maintain remission by week 52: a) prednisone: 15% (steroid naive), 5% (steroid veterans) b)triple dose infliximab: 35% (steroid naive), 15% (steroid veterans) c) continual infliximab: 75% (steroid naive), 55% (steroid veterans) Able to maintain remission by week 104: a) prednisone: 10% (steroid naive), 0% (steroid veterans) b) triple dose infliximab: 15% (steroid naive), 5% (steroid veterans) c) continual infliximab: 70% (steroid naive), 45% (steroid veterans) Conclusions: The treatment algorithm for Crohns Disease is evolving. Our findings support earlier application and continuation of infliximab in order to induce and maintain remission. The axiom “a lifelong illness requires lifelong therapy” leads to the corollary “a lifelong illness does not imply lifelong sickness.” These tenets need to be applied with constant vigilence.