Infliximab as Rescue Therapy for Moderate to Severe Colonic Crohnʼs Disease Requiring IV Corticosteroid Therapy

Purpose: Infliximab (IFX) has been shown to benefit patients with acute severe ulcerative colitis but its role as rescue therapy in severely active Crohn's colitis is less well documented. The primary objective of our study was to assess the frequency of medical treatment failure in these patients requiring IFX or IV corticosteroids (CS) alone for induction. Methods: The medical records of all patients hospitalized at the Centre Hospitalier Universitaire de Sherbrooke for acute severe Crohn's disease between 2001 and 2009 were retrospectively reviewed. Patients aged > 18 years old with colonic Crohn's disease, presenting with moderately to severely active disease [Harvey-Bradshaw Index (HBI)>9] requiring IV steroids were included. We assessed the frequency of urgent surgery. Steroid-free remission at 1 year, adverse events related to medical therapy and post-operative complications are also reported. Results: 114 patients were included in the study (64 women, median age 42 years, median disease duration 12 months, mean HBI score 16). Thirty-four patients were first diagnosed during the index hospitalization (29.8%) and 94 patients (92%) had isolated colonic Crohn's disease. CS alone were used in 79 patients; 35 patients required treatment with IFX due to lack of response to IV steroids. Eight of the 35 patients(22.9%) receiving IFX as rescue therapy required surgery during the hospital stay compared with 11 of the 79 (13.9%) who received iv CS alone (p=0.238). The two groups had similar post-operative complication rates except for a higher rate of thromboembolism in the IFX group (3 vs 0; p=0.058). Three patients (1 in IFX group, 2 in CS group) had a severe infection. Patients requiring IFX as rescue therapy had a more complicated disease defined as penetrating disease (11.4% vs 1.3%; p=0.03) or severe disease (80% vs 50.6%; p=0.027). Higher C-reactive protein (CRP), lower serum albumin level and higher rate of bleeding during the first 7 days of hospitalization tended to predict the need for infliximab as well as the need for urgent surgery. Steroid-free remission was achieved sooner in patients receiving infliximab compared with those who were managed with IV steroids alone (79.1 days vs 149.3 days; p=0.007). There was also a trend towards higher rates of steroid-free clinical remission at 1 year (56.2% vs 36.6%; p=0.062). Conclusion: The rate of urgent surgery was similar in patients receiving rescue infliximab or IV steroids alone for acute severe colonic Crohn's disease. Patients who successfully received infliximab as rescue therapy were more likely to be in steroid-free remission at 1 year than patients treated with IV steroids alone. They also received shorter steroid courses despite having more severe disease at presentation.Table. Outcomes

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