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The best approach to infliximab use in Crohn’s disease

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Professor Lovat
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Many people with Crohn’s disease now use infliximab to keep their illness under control. It is now widely recognised that this is a better approach than using steroids to induce remission. Steroids such as prednisolone cannot be used long-term as they have extensive side-effects.
Although infliximab does have some long-term side-effects, these are unusual and the majority people can take the medication successfully for long periods of time.

A new study sheds some light:

I have just read the outcome of a review of 10 years of infliximab use in the Netherlands. The study included 469 patients from 2 major hospitals. The average follow-up each patient was almost 5 years. It was published in the medical journal ‘Inflammatory Bowel Diseases’ at the end of 2013.

What the study shows

The vast majority of people (85%) had successful treatment of the initial illness with the drug. Most had long-term maintenance therapy meaning that they were treated every two months. In this group 61% remained in remission. A smaller number of patients had intermittent maintenance therapy. In other words sometimes they took the infliximab and sometimes they discontinued for a period. There has been a lot of concern about whether these people would develop antibodies which would make it impossible to retreat them. It turns out that in this study 48% of people who underwent intermittent maintenance therapy was successfully treated long-term as well. This is almost as good as those who took medication without stopping.

The added benefit of thiopurine drugs

Patients who took azathioprine or 6-mercaptopurine in the study had improved sustained benefit.
Although we know that there is a slightly increased risk of side effects combining infliximab with azathioprine, the improved sustained benefit may well override the small increased risk.

Risk of surgery is decreased

A lot of people with Crohn’s disease are concerned about the possibility of having surgery which indeed happens in about a third of patients. This study showed a reduction in abdominal surgery in the patients treated with infliximab who had a scheduled maintenance regime.

Cancer risk in people taking infliximab

Another concern people have is the likelihood of developing cancer. In this study risk was 0.7 for every 100 years of follow-up. Put another way, a person would need to live 140 years on average to get cancer whilst taking infliximab. This should be a great source of relief to the large numbers of people who now take this drug.

Who should take infliximab ?

Of course the question as to who should take infliximab remains. The debate continues as to whether to step up therapy which means starting with less intensive treatment and working up to more intensive treatment for people who fail to respond. The alternative approach is step down treatment. This means starting with the most powerful medicine and then when the person gets better reducing the potency and quantity of drug used. Clearly this is a decision which has to be made between the patient and their treating doctor. Therein remains the art of medicine!

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