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Accelerated Dosing of Infliximab Prevents Colectomy Within 90 Days in Only Half of Patients With Severe Ulcerative Colitis
Govani SM, Waljee AK, Stidham RW, Higgins P, Hardiman K. Accelerated Dosing of Infliximab Prevents Colectomy Within 90 Days in Only Half of Patients With Severe Ulcerative Colitis. Paper presented at: Digestive Disease Week Annual Conference; 2016 May 23; San Diego, CA.
Accelerated Dosing of Infliximab Prevents Colectomy Within 90 Days in Only Half of Patients with Severe Ulcerative Colitis
Shail M. Govani, Akbar K. Waljee, Ryan W. Stidham, Peter D.R. Higgins, Karin M. Hardiman
Infliximab (IFX) is effective in reducing colectomy among patients with steroid refractory severe ulcerative colitis (UC). Excessive stool losses of IFX may explain the lack of efficacy among non-responders. Accelerated dosing of IFX was shown to be efficacious in 1 study saving 93.3% of patients from colectomy during the induction period. Further use of accelerated dosing and its effect on surgical outcomes have not been reported. Here, we report the results of our center's experience with accelerated dosing of IFX compared to typical dosing for severe UC.
Our tertiary care center modified our Severe UC Protocol to accelerated dosing in which a 2nd dose of IFX was offered 3 days after the 1st if the C-reactive protein (CRP) had not declined sufficiently. We performed a retrospective review of patients with UC hospitalized and treated with infliximab between 1/1/2000 to 8/31/2015 at our institution. Patients were included if they were being started on IFX for the first time in the hospital. The outcomes of interest included colectomy within 90 days, readmission and post-operative complication (abscess, urinary tract infection, pneumonia, and rectal stump complication) rates within 30 days of colectomy. Comparisons were made using the chi-square test, Fishers exact test or Student's t-test using SAS 9.4.
During the study period, there were 57 patients with severe UC treated with IFX. Of these 17 received accelerated dosing, starting in 2013. The population was 61.4% female with an average age of 33.4 (+/- 12.2). The average disease duration was 5.4 years (+/- 7.0). The 90 day colectomy rate for typical dosing was 12.5% compared to 47.1% among those receiving accelerated dosing (p = 0.01). The average admission albumin and C-reactive protein (CRP) did not differ between the 2 groups. The average CRP on day of first IFX infusion was higher for accelerated dosing patients than typical dosing (5.8mg/dl +/- 3.9 vs 3.7mg/dl +/-3.0 respectively, p = 0.06) but the average decline in CRP between admission and 1st infusion was greater for accelerated dosing than typical dosing (2.0mg/dl +/- 4.4 for accelerated dosing vs. 5.1mg/dl +/- 6.1, p = 0.09). Twelve of the 13 patients who had a colectomy within 90 days underwent the procedure at our institution. For those patients who underwent colectomy, the 30 day post-operative readmission rate was higher among those given accelerated dosing (57.1% vs 20%, p = 0.29) but the post-operative complications were similar.
At our institution, accelerated dosing of IFX spared about 50% of patients from colectomy, far below the success rate reported in the initial study. Patients given accelerated dosing of IFX who underwent colectomy had an increased rate of 30 day readmissions. Larger studies are needed to understand the risks and benefits of administering accelerated dosing IFX.