Significative median MMS score decreased after infliximab therapy it was observed, from 9 (range: 7–10) to 1.0 (range: 0–3) (P < 0.0001).
Letters to the Editor
Letter: infliximab therapy in inflammatory bowel disease patients after liver transplantation
Article first published online: 18 MAR 2013
© 2013 Blackwell Publishing Ltd
Alimentary Pharmacology & Therapeutics
Volume 37, Issue 8, pages 840–842, April 2013
How to Cite
Indriolo, A., Fagiuoli, S., Pasulo, L., Fiorino, G., Danese, S. and Ravelli, P. (2013), Letter: infliximab therapy in inflammatory bowel disease patients after liver transplantation. Alimentary Pharmacology & Therapeutics, 37: 840–842. doi: 10.1111/apt.12256
- Issue published online: 18 MAR 2013
- Article first published online: 18 MAR 2013
- Manuscript Accepted: 30 JAN 2013
- Manuscript Received: 28 JAN 2013
We read with great interest the studies by Sandhu et al. and Mohabbat et al., which evaluated antitumour necrosis factor-alpha (TNFα) therapy for patients with refractory inflammatory bowel disease (IBD) post orthotopic liver transplant (OLT). To date, there have been only 18 patients treated with anti-TNF for relapsing IBD following OLT; this number includes patients with UC, CD, indeterminate colitis and pouchitis.[1-5] Such data are often not homogeneous in terms of administered therapy and outcomes.
We have evaluated the efficacy and safety of infliximab therapy in a homogeneous series of patients with refractory UC following OLT for advanced-stage primary sclerosing cholangitis (PSC). Four patients (all male patients; median age 39 years, range 22–54 years) with UC (n = 3) or pouchitis (n = 1) who underwent OLT were identified (Table 1). The median duration of infliximab therapy was 18 months (range: 3–30).
|Case||Age (years)||Gender||Indication for OLT||Age at PSC||Age at OLT||Anti rejection therapy||Age at UC||Duration of IFX therapy (months)||Pre-anti- IFX MSS||Post-anti-IFX MSS||Pre-anti-IFX PDAI||Post-anti-IFX PDAI||Pre-anti-IFX MCESI||Post-anti-IFX MCSI||Adverse events after IFX||Hepatic rejection|
|1||30||Male||PSC||12||24||Tacrolimus 1 mg + 1.5 mg/day; Azathiprine 75 mg/day; Prednisone 5 mg/day||5||30||10||0||–||–||3||0||Molluscum contagiosum||No|
|2||48||Male||PSC||23||42||Tacrolimus 3.5 mg + 3.5 mg/day||21||28||9||3||–||–||2||2||None||No|
|3||22||Male||PSC||15||16, 21||Ciclosporine 250 mg + 200 mg/day||12||3||7||1||–||–||2||Wait endoscopy||None|
|4||54||Male||PSC||42||45||Tacrolimus 1 mg + 1.5 mg/day; Sirolimus 3 mg/day||32||12||–||–||14||12||–||–||None||No|
|Tot.||Median age, range (years)||Gender||PSC||Median age, range (years)||Median age, range (years)||Median age, range (years)||Median age, range (months)||Median Pre-anti-IFX MSS, range||Median Post-anti-IFX MSS, range||Pre-anti-IFX PDAI||Post-anti-IFX PDAI||Median Pre-anti IFX MCESI, range|| |
|Number, percentage||Number, percentage|
|4||39 (22–54)||4/4 Male||4/4||19 (12–42)||33 (24–45)||16.5 (5–32)||18 (3–30)||9 (7–10)||1.0a (0–3)||14||12b||2 (2–3)||1 (0–2)||1/4 (25%)||0/4 (0%)|
Three patients (75%) experienced sustained improvement of IBD. A significant decrease in Mayo score was observed after infliximab therapy, from a mean score of 9.0 (range: 7–10) to a mean score of 1.0 (range: 0–3) (P < 0.0001) (Figure 1). At week 54, complete mucosal healing (defined as absence of lesions) was observed in one of three patients (33%). In the one patient with refractory pouchitis, a nonstatistically significant decrease in pouch disease activity index was observed (from 14 to 12). Subsequently, this patient presented with worsening of endoscopic lesions after interruption of infliximab therapy, and he underwent ileostomy.
Steroid treatment was successfully withdrawn during infliximab therapy in all patients. Adverse events included only one infection by Molluscum contagiosum, which resolved without sequelae. No malignancies were observed in any patient following infliximab therapy. No cases of hepatic rejection were documented. One patient (25%) presented with a recurrence of PSC 2 years before infliximab therapy (3 years after OLT) and he underwent a second OLT 5 years after the first.
Our results are consistent with the studies of Sandhu and Mohabbat and are in line with data on IBD patients who have not previously undergone liver transplantation. We assessed a homogenous series of refractory UC patients, who were treated with the same anti-TNFα agent. In previous studies, some patients were treated with infliximab[3-5] others with adalimumab and others patients with adalimumab for secondary loss of response to infliximab. Mucosal healing has been previously evaluated in only three studies.[1, 3-5] Moreover, in contrast to previous reports, we objectively assessed clinical response, utilising a clinical score for UC and pouchitis, and assessed mucosal healing using an endoscopic score.
In conclusion, our small study supports previous data on the efficacy and safety of infliximab therapy in patients with refractory UC after OLT, and adds new data on a homogenous population with UC and previous OLT, all treated by infliximab. Although no cases of hepatic graft dysfunction or rejection were observed, larger studies are need to evaluate the safety profile of biological therapy combined with anti rejection treatment in patients with refractory IBD following liver transplantation.
Declaration of personal and funding interests: None.
- 5Infliximab in patients with ulcerative colitis and primary sclerosing cholangitis before and after liver transplantation. JCC 2012; 6(Suppl. 1): S117., , , et al.