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Infliximab therapy for severe ulcerative colitis refractory to steroid therapy: Report of two cases
Abstracts
107
105 THE PREVALENCE OF AUTOIMMUNE THYROID DISEASE (ATD) IN PATIENTS WITH CELIAC DISEASE ICD) IS RELATED TO THE AGE AT DIAGNOSIS AND DURATION Ok E&‘OSURE TO GLUTEN. Calabti, w, D. Renzi, F Belli, D. Nigro, L. Herrera, II. Mallardi, and C. Surrenti GI Unit, Dept. of Clinical Gastmenterology, University of Florence Bwkgmund and aim: patients with CD are at increased risk of ATD, but the reason for this association is as yet unclear. The aim of IJUTstudy WBSto verify whether the prevalence of ATD in adult CD patients is related to the duration of exposure to gluten. Patim and nt.dhd, the study group comprised 204 CD patients diagnosed and prospectively followed up in our centre, in the period 1995-2000. The diagnosis of CD was based on the clinical history, laboratory and histological findings, and 8 good clinical response to a gluten fne diet. Thyroid micmsomal (TM) and thymglobulin (TG) antibodies were determined by indirect immunofluorescence and haemagglutination; in addition, free Ts and Ta and TSH were measured by standard RIAs to assess thyroid function. AtIer checking the diibution of the variables, Student 1 test was used to compare means, and Fisher’s exact test was adopted to compare percentages. Rsultv overall, an associated thyroid disorder was found in 73/204 patients (35 8%): 37 of them (50 7%) were hypothyroid, while the remaining 36 patients had TM and/or TG antibodies with a normal thyroid function. Female sex prevailed in CD patients with associated ATD (68/S vs. 97134, p = 0.001). The mean age at diaanosis of oatients with both CD and ATD (37 vears) ws sianificantlv higher than that of those with just CD (30 8 y&s: p <‘O.Ol); similarly, H significant difference ws found as far as the duration of exposure to gluten is concerned (38 vs. 326 years. resoectivelv: D < 0.01). Fin&. the prevalence of .&xiated Ae pr&ress&ly it&&d with’increas& the age at diagnosis and the duration of exposure to gluten (see table) / o-rnyeam I 21.40yean / 4140yeam I61-6cp~m age at diapnmis \snS (13.9%) 140/108(38.7%) 1X/50 (4&O%) 1 4/S (44.4%) exposure to gluten I4R9 (13.8%) ~41/118(35.3%) 123/49(46.9%) p10 (50.0%) Conclustim: these results confirm that ATD are exceedingly frequent in patients with adult CD, and suggest that the prevalence of associated autoimmune diseases may depend, at I& in part, on the duration of gluten exposure. Taken together, OUT data emphasize the importance of early detection of CD by serological screening in order to minimize the risk of developing ATD
POST-ERCP PANCREATITIS IS RELIABLY FORETOLD BY HYPERAMYLASEMIA GREATER THAN FIVE TIMES THE UPPER NORMAL LIMIT ASSOCIATED WITH 24-HOUR PANCREATICLIKE PAIN. P A Testoni’, F Bagn& F Lella2, C Natale’. M Prlmignani3 ‘Dwsron of Gasfmentemlcgy and Gastrointestinal Endoscopy, Unrversfty Vifa-Salute San Raffaele, lRCCS San Raffaefe Hospital, Milan. %epartmenf of Gastmentemlogy, Pol~clrnrco San Marco, Zingonia. b.epartment of Infernal Medicme Unwersify of Mflan lRCCS Ospedale Pohclmw Mflan, Italy Background The Incidence of post-ERCP/sphu?clerotomy pancreatltts 1s reported between 1 3% and 7 6% m prospectwe studies This range may likely reflect different defimtions of pancreatltls and methods of data collection Methods To Identify 24-hour clinical findings and enzymattc values consistent for clinkxl pancreatitis, the post-ERCP/sphmcterotomy course of 1165 procedures on Vat&s papilla was prospectwely recorded Patients were evaluated for pancreatic-llke pal”, WBC- count and serum amylases before and 24 hours after the procedure, pain and amylasemla were also recorded 6 to 6 hours after the procedure CT scan was performed I” all pattents with 24-hour pun associated with hyperamylasemia greater than three times the normal Addittonal 24-hour follow-up was performed in patlenls with &her 24-hour hyperamylasemla greater than five times the normal or 24-hour pancreatic pan independent from enzymatic level All patlents were clinically evaluated at 40 hours Results Pancreatic-llke pam never occurred I” cases wth amylasemia lower than three times the normal, It was significantly (p c 0 001) associated wth hyperamylasemla greater than five times the normal, either 6-6 hours or 24 hours after the procedure Leukocvtosls and CT scan findmas consistent for oancreatltls were observed only among cases (4li% and 29 5%, &pectwely) wth 24-hour hyperamylasemta greater than five times the normal None of the 16 patients wth 24.hour paw and hyperamylasemia lower than five times the normal had symptoms still persisting at 46 hours Twenty-fwe (41 7%) of the 60 patients wth 24.hour pa,” and hyperamylasemla higher than five times the normal had 4Ehour pawn and hyperamylasemla. Conclusions Only among patients with 24. hour pancreatic-llke pal” and hypetamyiasemia higher than fwe times the normal. features cornstent for clinical pancreatltts were present and addltlonal 24-hour follow-up IS requtred
106 INFLIXIMAB THERAPY FOR SEVERE ULCERATIVE COLITIS REFRACTORY TO STEROID THERAPY: REPORT OF TWO CASES. K&n A Cosintino R, Falasco G and Prantera C. Division of Gastroenterology. Azienda Ospedalieti S. Camille - Forlanini, Rome, Italy Background: Monoclonal antibodies against TNFalfa (Infliximab) are an effective treatment for moderate to severe inflammatory and fistulising Crohn’s disease. No data has been published up to now about the effects of Infliximab in patients with ulcerative colitis (UC). Preliminary results (Chey WY 2000: data on file) suggest a clinical and endoscopical improvement after Intliximab in UC refractory to conventional medical treatment. Aim: To report the clinical outcome of two patients with severe active UC whose condition has not improved after 7 days of intravenous corticosteroid therapy. Methods: Two male patients (MF, CR) with severe active UC diagnosed histologically six and respectively seven years earlier, has been treated with Infliximab 5 mg/Kg/ iv after failing 7 days of metilprednisolone 60 mg administered by continous intravenous infusion. Clinical activity was evaluated by a clinical activity index (CAI) (1) based on numerical symptom score with a maximal score of 21; a score of less than 10 on two consecutive days was considered to indicate a positive respons’e to therapy and the score on the second of these two days was considered the final score. All patients were receiving total parenteral nutrition but oral intake of food was allowed if requested by the patient. Results: All two patients had a response to therapy (CAI< 10) within 2 (MF) and 5 (CR) days. The clinical activity score fell from 18 to 7 (MF) and from I6 to 6 (CR). Oral intake of food was resumed after 5 (MF) and 4 (CR) days, and patients were discharged after 11 and 15 days respectively. Conclusions: Infliximab was rapidly effective for two patients with severe conticosteroid-resistant ulcerative colitis. (1) Lichtiger S, Present DH, Kombluth A, et al. Cyclosporine in severe ulcerative colitis refractory to steroid therapy. N Engl J Med 1994;330:1841-1845.
THE I’ERmON OF QU4LI’IY OF LIFE IN INFLAMMATORY BOWEL DISEASE (IBD) MAINLY DEPENDS ON DISEASE ACIIVITY .->SaibeniS TatamllaM,Rivolta RCcsklliniA,RadaA,FeuatisI,CdomboE,AhrisiC,~G, Rondc&~deFmnchkRMilano,McmqRhqMelquno,Viixsg (h&mte,PaGqCyrm&MfdG.SMIJ.(GmppodiSbJdioperk I r . Ittlddii.lTALY. Badqqound:TheevahmtiwfHcalthRekdQual@ofLik(HRC$L) pnn&sanew&nmsionintheevaluationof@ktts(p&)withtBD. Aim: to w&ate HRQoL in IJ3D p acc&ing to disease adivity. Metho&:wc&nitkdthehaIianQw&xmakcaQu&yofLi& OQW) to IED P amsecuklys&nattk8ptitk@@~, lQQoLwaSnXdmS&datradhae~wheIl~inactivityOr dIemf?jwXuedalrlbef~andatkrslRgery.TheIQQoLe%%&atS int&nal(8items)andsyskmic(7,lsymptamsanotional(9)andsocial funckm(5).ToialsmngesfknOto87~thel1igherthe~the worse ihe HR@L. ReXiits; 107 p&s wiul cltws Disease (CD) (53 men) and145@stiUke&wG~litis(UC)(78naen)enrolled 19CDptsand 49ucp&h%ladivediseaXIQQoLw;s~to135~:97 vddmdfieddiseaseactivity, 17withwcrseneddiseaseactivityand21 wiIhiIllpmddisea8eactivity.Amalgimmcdi6cdpts,meantctaIscane andallmeanscuesofsiogledomainsdidnot&owsigniticant&nges behKeenth:madministrationsAnlongwolsaKdptrithemeanto?aI scoreinr;reased~15.3t92to26.9_+121~.001ka~patlw wasf6undinaudumainsAmcmgimpmvedpatientsulemeanmtalsccre dtqxtd fiun 282 _+ 16.0 to 17.8 f 13.1 (~&1.001); a similar paarm was fxltKlinaudomaiqexceptinsocialfinctionwhaethedeae;seisonly very close fo sii&id LS@&SY &=0.052). Conddonst IBD p&c&+ tixtivc&easehaveawxsepaceptionoftheirHRQoLthanthoseti aqui~phast.TheIQQoLseanstokwysmsitixto&ings0f dka8eidvily.J.n~~~adivayappesrsbethe~ihatm6inIy klflU!%cesQualayOfLifepaception.
107
105 THE PREVALENCE OF AUTOIMMUNE THYROID DISEASE (ATD) IN PATIENTS WITH CELIAC DISEASE ICD) IS RELATED TO THE AGE AT DIAGNOSIS AND DURATION Ok E&‘OSURE TO GLUTEN. Calabti, w, D. Renzi, F Belli, D. Nigro, L. Herrera, II. Mallardi, and C. Surrenti GI Unit, Dept. of Clinical Gastmenterology, University of Florence Bwkgmund and aim: patients with CD are at increased risk of ATD, but the reason for this association is as yet unclear. The aim of IJUTstudy WBSto verify whether the prevalence of ATD in adult CD patients is related to the duration of exposure to gluten. Patim and nt.dhd, the study group comprised 204 CD patients diagnosed and prospectively followed up in our centre, in the period 1995-2000. The diagnosis of CD was based on the clinical history, laboratory and histological findings, and 8 good clinical response to a gluten fne diet. Thyroid micmsomal (TM) and thymglobulin (TG) antibodies were determined by indirect immunofluorescence and haemagglutination; in addition, free Ts and Ta and TSH were measured by standard RIAs to assess thyroid function. AtIer checking the diibution of the variables, Student 1 test was used to compare means, and Fisher’s exact test was adopted to compare percentages. Rsultv overall, an associated thyroid disorder was found in 73/204 patients (35 8%): 37 of them (50 7%) were hypothyroid, while the remaining 36 patients had TM and/or TG antibodies with a normal thyroid function. Female sex prevailed in CD patients with associated ATD (68/S vs. 97134, p = 0.001). The mean age at diaanosis of oatients with both CD and ATD (37 vears) ws sianificantlv higher than that of those with just CD (30 8 y&s: p <‘O.Ol); similarly, H significant difference ws found as far as the duration of exposure to gluten is concerned (38 vs. 326 years. resoectivelv: D < 0.01). Fin&. the prevalence of .&xiated Ae pr&ress&ly it&&d with’increas& the age at diagnosis and the duration of exposure to gluten (see table) / o-rnyeam I 21.40yean / 4140yeam I61-6cp~m age at diapnmis \snS (13.9%) 140/108(38.7%) 1X/50 (4&O%) 1 4/S (44.4%) exposure to gluten I4R9 (13.8%) ~41/118(35.3%) 123/49(46.9%) p10 (50.0%) Conclustim: these results confirm that ATD are exceedingly frequent in patients with adult CD, and suggest that the prevalence of associated autoimmune diseases may depend, at I& in part, on the duration of gluten exposure. Taken together, OUT data emphasize the importance of early detection of CD by serological screening in order to minimize the risk of developing ATD
POST-ERCP PANCREATITIS IS RELIABLY FORETOLD BY HYPERAMYLASEMIA GREATER THAN FIVE TIMES THE UPPER NORMAL LIMIT ASSOCIATED WITH 24-HOUR PANCREATICLIKE PAIN. P A Testoni’, F Bagn& F Lella2, C Natale’. M Prlmignani3 ‘Dwsron of Gasfmentemlcgy and Gastrointestinal Endoscopy, Unrversfty Vifa-Salute San Raffaele, lRCCS San Raffaefe Hospital, Milan. %epartmenf of Gastmentemlogy, Pol~clrnrco San Marco, Zingonia. b.epartment of Infernal Medicme Unwersify of Mflan lRCCS Ospedale Pohclmw Mflan, Italy Background The Incidence of post-ERCP/sphu?clerotomy pancreatltts 1s reported between 1 3% and 7 6% m prospectwe studies This range may likely reflect different defimtions of pancreatltls and methods of data collection Methods To Identify 24-hour clinical findings and enzymattc values consistent for clinkxl pancreatitis, the post-ERCP/sphmcterotomy course of 1165 procedures on Vat&s papilla was prospectwely recorded Patients were evaluated for pancreatic-llke pal”, WBC- count and serum amylases before and 24 hours after the procedure, pain and amylasemla were also recorded 6 to 6 hours after the procedure CT scan was performed I” all pattents with 24-hour pun associated with hyperamylasemia greater than three times the normal Addittonal 24-hour follow-up was performed in patlenls with &her 24-hour hyperamylasemla greater than five times the normal or 24-hour pancreatic pan independent from enzymatic level All patlents were clinically evaluated at 40 hours Results Pancreatic-llke pam never occurred I” cases wth amylasemia lower than three times the normal, It was significantly (p c 0 001) associated wth hyperamylasemla greater than five times the normal, either 6-6 hours or 24 hours after the procedure Leukocvtosls and CT scan findmas consistent for oancreatltls were observed only among cases (4li% and 29 5%, &pectwely) wth 24-hour hyperamylasemta greater than five times the normal None of the 16 patients wth 24.hour paw and hyperamylasemia lower than five times the normal had symptoms still persisting at 46 hours Twenty-fwe (41 7%) of the 60 patients wth 24.hour pa,” and hyperamylasemla higher than five times the normal had 4Ehour pawn and hyperamylasemla. Conclusions Only among patients with 24. hour pancreatic-llke pal” and hypetamyiasemia higher than fwe times the normal. features cornstent for clinical pancreatltts were present and addltlonal 24-hour follow-up IS requtred
106 INFLIXIMAB THERAPY FOR SEVERE ULCERATIVE COLITIS REFRACTORY TO STEROID THERAPY: REPORT OF TWO CASES. K&n A Cosintino R, Falasco G and Prantera C. Division of Gastroenterology. Azienda Ospedalieti S. Camille - Forlanini, Rome, Italy Background: Monoclonal antibodies against TNFalfa (Infliximab) are an effective treatment for moderate to severe inflammatory and fistulising Crohn’s disease. No data has been published up to now about the effects of Infliximab in patients with ulcerative colitis (UC). Preliminary results (Chey WY 2000: data on file) suggest a clinical and endoscopical improvement after Intliximab in UC refractory to conventional medical treatment. Aim: To report the clinical outcome of two patients with severe active UC whose condition has not improved after 7 days of intravenous corticosteroid therapy. Methods: Two male patients (MF, CR) with severe active UC diagnosed histologically six and respectively seven years earlier, has been treated with Infliximab 5 mg/Kg/ iv after failing 7 days of metilprednisolone 60 mg administered by continous intravenous infusion. Clinical activity was evaluated by a clinical activity index (CAI) (1) based on numerical symptom score with a maximal score of 21; a score of less than 10 on two consecutive days was considered to indicate a positive respons’e to therapy and the score on the second of these two days was considered the final score. All patients were receiving total parenteral nutrition but oral intake of food was allowed if requested by the patient. Results: All two patients had a response to therapy (CAI< 10) within 2 (MF) and 5 (CR) days. The clinical activity score fell from 18 to 7 (MF) and from I6 to 6 (CR). Oral intake of food was resumed after 5 (MF) and 4 (CR) days, and patients were discharged after 11 and 15 days respectively. Conclusions: Infliximab was rapidly effective for two patients with severe conticosteroid-resistant ulcerative colitis. (1) Lichtiger S, Present DH, Kombluth A, et al. Cyclosporine in severe ulcerative colitis refractory to steroid therapy. N Engl J Med 1994;330:1841-1845.
THE I’ERmON OF QU4LI’IY OF LIFE IN INFLAMMATORY BOWEL DISEASE (IBD) MAINLY DEPENDS ON DISEASE ACIIVITY .->SaibeniS TatamllaM,Rivolta RCcsklliniA,RadaA,FeuatisI,CdomboE,AhrisiC,~G, Rondc&~deFmnchkRMilano,McmqRhqMelquno,Viixsg (h&mte,PaGqCyrm&MfdG.SMIJ.(GmppodiSbJdioperk I r . Ittlddii.lTALY. Badqqound:TheevahmtiwfHcalthRekdQual@ofLik(HRC$L) pnn&sanew&nmsionintheevaluationof@ktts(p&)withtBD. Aim: to w&ate HRQoL in IJ3D p acc&ing to disease adivity. Metho&:wc&nitkdthehaIianQw&xmakcaQu&yofLi& OQW) to IED P amsecuklys&nattk8ptitk@@~, lQQoLwaSnXdmS&datradhae~wheIl~inactivityOr dIemf?jwXuedalrlbef~andatkrslRgery.TheIQQoLe%%&atS int&nal(8items)andsyskmic(7,lsymptamsanotional(9)andsocial funckm(5).ToialsmngesfknOto87~thel1igherthe~the worse ihe HR@L. ReXiits; 107 p&s wiul cltws Disease (CD) (53 men) and145@stiUke&wG~litis(UC)(78naen)enrolled 19CDptsand 49ucp&h%ladivediseaXIQQoLw;s~to135~:97 vddmdfieddiseaseactivity, 17withwcrseneddiseaseactivityand21 wiIhiIllpmddisea8eactivity.Amalgimmcdi6cdpts,meantctaIscane andallmeanscuesofsiogledomainsdidnot&owsigniticant&nges behKeenth:madministrationsAnlongwolsaKdptrithemeanto?aI scoreinr;reased~15.3t92to26.9_+121~.001ka~patlw wasf6undinaudumainsAmcmgimpmvedpatientsulemeanmtalsccre dtqxtd fiun 282 _+ 16.0 to 17.8 f 13.1 (~&1.001); a similar paarm was fxltKlinaudomaiqexceptinsocialfinctionwhaethedeae;seisonly very close fo sii&id LS@&SY &=0.052). Conddonst IBD p&c&+ tixtivc&easehaveawxsepaceptionoftheirHRQoLthanthoseti aqui~phast.TheIQQoLseanstokwysmsitixto&ings0f dka8eidvily.J.n~~~adivayappesrsbethe~ihatm6inIy klflU!%cesQualayOfLifepaception.