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Infusion Reaction to Infliximab in a Patient with Rheumatoid Arthritis After Discontinuation Over 1 Year and Readministration To the Editor: We read with interest the article by Baraliakos, et al concerning no increase in incidence of infusion reactions after infliximab readministration in patients with ankylosing spondylitis1. In some rheumatoid arthritis (RA) cases, this treatment has to be discontinued due to infusion reactions2. Overall, the incidence of infusion reaction to infliximab is about 5% of cases in Crohn's disease (CD)3,4, and as recently reported, when combined with glucocorticoid therapy, from 4.6% to 8.6% in RA5. Further, delayed infusion reactions in CD were reported in 25% of patients who received infliximab again after a 2–4 year interval without infliximab treatment3. Uthman, et al described cases of patients with RA and history of severe acute infusion reaction to infliximab who subsequently underwent successful infusion using a prophylactic treatment with a combination of H1 and H2 receptor blockers, hydrocortisone, and diphenhydramine6. We describe a case of infliximab discontinuation due to infusion reaction after a hiatus of more than one year between treatments despite its efficacy for symptoms. The patient was a 65-year-old Japanese woman with RA. She was treated in the earliest years with methotrexate (MTX) and prednisolone (PSL). However, disease activity remained high despite those medications. Infliximab (3 mg/kg) was added to PSL and MTX at Weeks 0, 2, and 6, followed by administration every 8 weeks. She initially had a significant decrease in disease activity. Despite its efficacy for symptoms, infliximab was discontinued because interstitial pneumonitis occurred after 6 infusions. After her recovery, she was again treated with MTX, and switched to etanercept. Etanercept proved ineffective, prompting readministration of infliximab after a 14 month interval. The Japanese Ministry of Health, Labor and Welfare had just approved the use of infliximab and etanercept for RA at that time. To prevent infusion reactions, the infusion rate of infliximab was modulated and the patient was premedicated with a combination of H1 and H2 receptor blockers and hydrocortisone. There was no reaction following the first infusion, and swelling and tenderness decreased. However, during the second infusion, she experienced very severe urticaria and pruritus 60 min after the commencement of infusion. Infusion was immediately stopped, and she received 5 mg of diphenhydramine with lactate Ringer's solution intravenously. The symptoms disappeared completely. A recent study reported that second infusion 20 weeks or more from the first infusion in CD was a notable risk factor for development of infusion reaction7. Similarly, in Japanese patients with RA, large-scale postmarketing surveillance showed that serious infusion reactions were more commonly observed in participants of the previous clinical trial of infliximab8, and the majority of reactions occurred at the time of the second infliximab infusion after a hiatus of over 2 years (data on file; Mitsubishi Tanabe Pharma, Japan). The pathophysiology of infusion reactions remains elusive. One possibility is the development of antibodies to infliximab (ATI) — the incidence of ATI has been reported at between 10% and 60%9,10. However, the correlation between ATI and infusion reactions does not appear to be very strong9. Although we were unable to measure its concentration in this case, serum ATI is often not measured because it is undetectable when infliximab is also present in the serum1. Therefore, further investigation is required to establish whether the rate of the infusion reaction is influenced by previous administration of this agent in RA. HIROE TOKI, MD; SHIGEKI MOMOHARA, MD, PhD; SO TSUKAHARA, MD, PhD; KATSUNORI IKARI, MD, PhD, Institute of Rheumatology, Tokyo Women's Medical University, 10-22 Kawada, Shinjuku, Tokyo, 162-0054, Japan. Address reprint requests to Dr. S. Momohara, Institute of Rheumatology, Tokyo Women's Medical University, 10-22 Kawada, Shinjuku, Tokyo, 162-0054, Japan. E-mail: smomohara@ior.twmu.ac.jp 2. Shergy WJ, Isern RA, Cooley DA, et al. Open label study to assess infliximab safety and timing of onset of clinical benefit among patients with rheumatoid arthritis. J Rheumatol 2002;29:667-77. [MEDLINE] 3. Cheifetz A, Smedley M, Martin S, et al. The incidence and management of infusion reactions to infliximab: a large center experience. Am J Gastroenterol 2003;98:1315-24. [MEDLINE] 4. Hanauer SB, Feagan BG, Lichtenstein GR, et al. Maintenance infliximab for Crohn's disease: the ACCENT I randomised trial. Lancet 2002;359:1541-9. [MEDLINE] 5. Augustsson J, Eksborg S, Ernestam S, Gullstrom E, van Vollenhoven R. Low-dose glucocorticoid therapy decreases risk for treatment-limiting infusion reaction to infliximab in patients with rheumatoid arthritis. Ann Rheum Dis 2007;66:1462-6. [MEDLINE] 6. Uthman I, Touma Z, El-Sayyad J, Zaitoun F. Successful retreatment with infliximab in patients with prior severe infusion reactions. Clin Rheumatol 2006;25:540-1. [MEDLINE] 7. Kugathasan S, Levy MB, Saeian K, et al. Infliximab retreatment in adults and children with Crohn's disease: risk factors for the development of delayed severe systemic reaction. Am J Gastroenterol 2002;97:1408-14. [MEDLINE] 8. Takeuchi T, Tatsuki Y, Nogami Y, et al. Postmarketing surveillance of the safety profile of infliximab in 5000 Japanese patients with rheumatoid arthritis. Ann Rheum Dis 2008;67:189-94. [MEDLINE] 9. Baert F, Noman M, Vermeire S, et al. Influence of immunogenicity on the long-term efficacy of infliximab in Crohn's disease. N Engl J Med 2003;348:601-8. [MEDLINE] 10. Hanauer SB, Wagner CL, Bala M, et al. Incidence and importance of antibody responses to infliximab after maintenance or episodic treatment in Crohn's disease. Clin Gastroenterol Hepatol 2004;2:542-53. [MEDLINE]
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