Version June 2024
| Infliximab | Cyclosporine | Tacrolimus | |
| Tests before treatment | Excluding tuberculosis; serology for varicella, hepatitis B, and hepatitis C (and HIV when appropriate). | CBC, chemistries including creatinine and magnesium, liver tests, EBV titers, spot creatinine clearance. | CBC, chemistries including creatinine and magnesium, liver tests, EBV titers, spot creatinine clearance. |
| Initial dosing | 5 to 10 mg/kg for dose 1. Emerging data in ASC indicate that intensified induction is more successful than standard 5 mg/kg given at weeks 0, 2, and 6. | 2 mg/kg/day continuous intravenous infusion. | 0.1 mg/kg per dose orally twice daily. |
| Main toxicity | Infusion reactions, immune suppression, and rare opportunistic infections. | Hypertension, hyperglycemia, hypomagnesemia, immune suppression, azotemia, seizures (dose- and hypercholesterolemia-dependent), hirsutism, gingival hyperplasia. | As per cyclosporine, but less hirsutism and gingival hyperplasia. Additionally, self-remitting tremor. |
| Ongoing treatment following response | Continue regularly scheduled maintenance infusions (4 to 8 weeks), ideally guided by therapeutic drug monitoring. | Initiate thiopurines (or other agent to maintain remission such as vedolizumab) so that cyclosporine can be discontinued within several months. | As per cyclosporine. |
| Target drug levels during induction | Limited data on target levels during induction. | Aim initially for 150 to 300 ng/mL. | Aim initially for 10 to 15 ng/mL. |
| Target levels once response achieved | 5 to 10 microgram/mL at trough during maintenance. | 100 to 200 ng/mL once remission achieved. | 5 to 7 ng/mL once remission achieved; longer duration treatment using lower levels of 2 to 5 have been reported. |
| Monitoring/prevention of toxicity | PJP prophylaxis to be considered with IMM and steroids. | PJP prophylaxis to be strongly considered with IMM and steroids. Monitor drug levels, creatinine, glucose, electrolytes (including magnesium), lipid levels, blood pressure. | PJP prophylaxis to be strongly considered with IMM and steroids. Monitor drug levels, creatinine, glucose, electrolytes (including magnesium), lipid levels, blood pressure. |
This table outlines the main options for medical therapy of acute severe ulcerative colitis in children that is refractory to treatment with glucocorticoids (ie, no clinically meaningful response to a 7- to 10-day course of intravenous glucocorticoids). Use of sequential therapy (infliximab followed by cyclosporine or tacrolimus, or vice versa) remains controversial and is not recommended.
If the patient with severe or refractory colitis responds to rescue therapy with cyclosporine, tacrolimus, or infliximab, then the glucocorticoids can be gradually tapered and withdrawn. If cyclosporine or tacrolimus was used for induction, the patient should be transitioned to a thiopurine or other long-term maintenance agent within 3 to 4 months.CBC: complete blood count; EBV: Epstein-Barr virus; ASC: acute severe colitis; IMM: immunomodulators; PJP: Pneumocystis jiroveci pneumonia.
* Maintenance therapy can be given every 8 weeks after induction, if clinically indicated.
¶ Neurotoxicity (manifested as paresthesias, tremors, and seizures) is promoted by hypocholesterolemia (<120 mg/dL) and hypomagnesemia (<1.5 mg/dL); if the latter occurs, dose of cyclosporine should be lowered.
Δ Hypertension can be seen in up to 40% of subjects and usually responds to calcium channel blockers (the latter, however, can increase cyclosporine levels).
◊ Serum creatinine >1.4 mg/dL or at least 33% over baseline (usually respond to cyclosporine dose adjustment).
§ Drug interactions should be checked with Lexi-Interact when initiated and for any change in drug therapy.
¥ If oral drug dose has been changed, monitor levels 1 week later.آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟
