Published online May 6, 2021. doi: 10.12998/wjcc.v9.i13.3219
Peer-review started: January 9, 2021
First decision: January 24, 2021
Revised: February 4, 2021
Accepted: March 9, 2021
Article in press: March 9, 2021
Published online: May 6, 2021
Processing time: 102 Days and 22.7 Hours
Acute severe ulcerative colitis (ASUC) is a complication of ulcerative colitis associated with high levels of circulating tumor necrosis factor alpha, due to the intense inflammation and faster stool clearance of anti-tumor necrosis factor drugs. Dose-intensified infliximab treatment can be beneficial and is associated with lower rates of colectomy. The aim of the study was to present a case of a patient with ASUC and megacolon, treated with hydrocortisone and accelerated scheme of infliximab that was monitored by drug trough level.
A 22-year-old female patient diagnosed with ulcerative colitis, presented with diarrhea, rectal bleeding, abdominal pain, vomiting, and distended abdomen. During investigation, a positive toxin for Clostridium difficile and colonic dilatation of 7 cm consistent with megacolon were observed. She was treated with oral vancomycin for pseudomembranous colitis and intravenous hydrocortisone for severe colitis, which led to the resolution of megacolon. Due to the persistent severe colitis symptoms, infliximab 5 mg/kg was prescribed, monitored by drug trough level (8.8 μg/mL) and fecal calprotectin of 921 μg/g (< 30 μg/g). Based on the low infliximab trough level after one week from the first infliximab dose, the patient received a second infusion at week 1, consistent with the accelerated regimen (infusions at weeks 0, 1, 2 and 6). We achieved a positive clinical and endoscopic response after 6 mo of therapy, without the need for a colectomy.
Infliximab accelerated infusions can be beneficial in ASUC unresponsive to the treatment with intravenous corticosteroids. Longitudinal studies are necessary to define the best therapeutic drug monitoring and treatment regimen for these patients.
Core Tip: Acute severe ulcerative colitis (ASUC) is associated with high circulating levels of tumor necrosis factor-alpha, due to intense inflammation and faster stool clearance of the anti-tumor necrosis factor drug. Consequently, these patients may need higher doses or more frequent administrations of infliximab. A young patient with a recent diagnosis of ulcerative colitis presenting with ASUC associated with megacolon, was successfully treated with intravenous corticosteroids and an accelerated infliximab regimen, based on the serum levels of the medication. Despite the favorable outcome in the case reported, longitudinal studies are necessary to define the best therapeutic drug monitoring and treatment regimen for these patients.