P1686 - Successive Use of Infliximab and Cyclosporine as Salvage Therapy in Acute Severe Ulcerative Colitis

Monday, October 25, 2021

10:30 AM – 4:15 PM PT

Location: Shoreline Exhibit Hall

Has Audio

Presenting Author(s)

Joshua M. Steinberg, MD

University of Chicago Medicine Inflammatory Bowel Disease Center
Chicago, IL, United States

Joshua M. Steinberg, MD¹, Nathaniel A. Cohen, MBBCh¹, Tina G. Rodriguez, BA¹, Sushila R. Dalal, MD¹, David T. Rubin, MD, FACG²
¹University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL; ²University of Chicago Medicine, Inflammatory Bowel Disease Center, Chicago, IL

Introduction: Nearly 25% of patients with Ulcerative Colitis (UC) may develop acute severe UC (ASUC) requiring hospitalization, of which 40% will result in colectomy. Current guidelines recommend rescue therapy with either infliximab (IFX) or cyclosporine (CSA) if patients don’t respond to IV corticosteroids (IVCS). We describe two cases of ASUC in which patients who failed IFX salvage therapy received subsequent treatment with CSA.

Case Description/Methods: Case 1
A 41-year-old man with an 18 year history of left sided UC treated with azathioprine was lost to follow up after self-discontinuing therapy in 2013. In July 2020, he presented with severe bloody diarrhea, urgency and a 20-pound weight loss. Despite oral prednisone he was admitted to an outside hospital (OSH) with ASUC. A flex sig revealed severe colitis (image 1), with biopsies consistent with CMV and he was started on IV valgancilovir. He received one dose of IFX 10mg/kg without response (IFX level 8.4). He was transferred to our center and received 2mg/kg IV CSA 13 days following the IFX dose. He dramatically improved, CRP normalized (see table 1) and was discharged home. After 9 months of follow up, he is in clinical remission on vedolizumab (VDZ) monotherapy having successfully tapered off steroids and cyclosporine.

Case 2
A 21-year-old woman with an 11 year history of UC maintained on mesalamine presented with progressively worsening abdominal cramps, bloody diarrhea, and a 20 pound weight loss. Despite oral prednisone, a colonoscopy revealed severe pancolitis, and she was admitted to OSH with ASUC and C diff, and was treated with oral vancomycin. She received one dose of IFX 10mg/kg without improvement and was transferred to our center. She received 3mg/kg of CSA (7 days following IFX dose) with marked clinical improvement, although she experienced headache that was medically managed. After two months of follow up she remains in clinical remission with a VDZ bridge, and will be stopping CSA following her third VDZ dose.

There were no severe adverse events in either patient.

Discussion: We demonstrate the effectiveness and safety in two patients with ASUC of CSA after IVCS and infliximab failed. Both patients were subsequently maintained with vedolizumab. This approach to salvage therapy can be considered in select patients.

Figure: Flex sig of case 1 revealing endoscopically severely active colitis in a patient with ASUC (Mayo UC score 3).

	Case 1 Admission	Case 1 Discharge	Case 2 Admission	Case 2 Discharge
Hgb	9.1	10.8	11.5	11.2
CRP	15	< 3	13	< 3
Albumin	2.8	3.4	3.9	3.3
WBC	15.4	12.3	13.2	9.6
IFX level	8.4	N/A	N/A	N/A

Table: Admission and discharge laboratory values for case 1 and 2.

Disclosures:

Joshua Steinberg: Pfizer – Advisory Committee/Board Member.

Nathaniel Cohen indicated no relevant financial relationships.

Tina Rodriguez indicated no relevant financial relationships.

Sushila Dalal: Abbvie – Advisory Committee/Board Member, Speaker's Bureau. Pfizer – Advisory Committee/Board Member, Consultant.

David Rubin: Abbvie – Consultant. Allergan, Inc. – Consultant. Altrubio – Consultant. Arena Pharmaceuticals – Consultant. Athos Therapeutics – Consultant. Bellatrix Pharmaceuticals – Consultant. Boehringer Ingelheim, Ltd. – Consultant. Bristol-Myers Squibb – Consultant. Celgene Corp/Syneos – Consultant. Connect BioPharma – Consultant. GalenPharma/Atlantica – Consultant. Genentech/Roche – Consultant. Gilead Sciences – Consultant. InDex Pharmaceuticals – Consultant. Ironwood Pharmaceuticals – Consultant. Iterative Scopes – Consultant. Janssen Pharmaceuticals – Consultant. Lilly – Consultant. Materia Prima – Consultant. Pfizer – Consultant. Prometheus Biosciences – Consultant. Reistone – Consultant. Takeda – Consultant, Grant/Research Support. Techlab, Inc. – Consultant.

Joshua M. Steinberg, MD¹, Nathaniel A. Cohen, MBBCh¹, Tina G. Rodriguez, BA¹, Sushila R. Dalal, MD¹, David T. Rubin, MD, FACG². P1686 - Successive Use of Infliximab and Cyclosporine as Salvage Therapy in Acute Severe Ulcerative Colitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.