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THE SAFETY AND EFFICACY OF ANTI-TUMOR NECROSIS FACTOR-ALPHA THERAPY FOR INFLAMMATORY BOWEL DISEASE IN PATIENTS POST-LIVER TRANSPLANTATION: A CASE SERIES
A Sandhu1, T AlAmeel2, C Dale1, M Levstik1, N Chande11London Health Sciences Centre, London, ON; 2University of Alberta, Edmonton, AB
Aims: To investigate the safety and efficacy of anti-tumor necrosis factor-alpha (anti-TNF) therapy for refractory inflammatory bowel disease (IBD) in the post-liver transplantation population.
Methods: The liver transplant database at London Health Sciences Centre was searched to identify adult patients with IBD post-transplantation. These patients were subsequently reviewed to identify those who had received anti-TNF therapy.
Results: Seven patients (six male, one female) were identified, aged 26 to 65 years of age. All patients had orthotopic liver transplants. Five required transplantation due to primary sclerosing cholangitis, one due to autoimmune hepatitis, and one due to biliary atresia. With respect to their IBD, six patients definitively suffered from Crohn's disease (CD). Of these, two were initially suspected to have ulcerative colitis (UC); however, following colectomy, both patients developed active ileitis and were deemed to have CD. The remaining seventh patient had pancolitis on colonoscopy with granulomas on biopsies and was diagnosed with indeterminate colitis. Four patients were diagnosed with IBD prior to transplantation and three after transplantation.
Of the seven patients, all were treated with infliximab 5 mg/kg every 8 weeks after undergoing induction at weeks 0, 2 and 6. The duration of infliximab therapy ranged from three months to five years at the time of data collection. Six patients treated with infliximab experienced significant improvement of their IBD symptoms post-transplantation, with improved abdominal pain, and decreased frequency and increased consistency of bowel movements. The one remaining patient, originally diagnosed with UC post-transplantation, lost response after 16 months of infliximab therapy. He ultimately required a colectomy and ileo-anal pouch procedure but experienced continued symptoms one year post-operatively and active ileitis was discovered. He was then started on adalimumab due to these unremitting symptoms. His adalimumab dose was 40 mg subcutaneously every week, increased from every other week, but he did not have sustained improvements of his IBD. No patients experienced significant side effects from anti-TNF therapy, despite being on multiple anti-rejection immunosuppressive medications. As such, there were no infections, demyelinating disease, malignancy or induction of auto-immunity in these patients.
Conclusions: Based on this case series, anti-TNF therapy appears to be safe and effective for treating refractory IBD in patients post-liver transplantation. These patients respond to anti-TNF therapy similarly to those who have not been previously transplanted. To date, this is the largest case series on this rarely documented population.