Should a patient with inflammatory bowel disease (IBD) in clinical and endoscopic remission, being treated with infliximab (chimeric monoclonal antibody against tumor necrosis factor alpha), continue their current treatment plan despite having minor psoriasis limited to the scalp?

From the Guidelines

The patient should continue with their current treatment plan, as the benefits of maintaining remission in inflammatory bowel disease (IBD) outweigh the risks associated with minor psoriasis limited to the scalp. The patient has been on infliximab since 2010 and has achieved clinical and endoscopic remission, with the last colonoscopy showing a Rutgeerts score of i1, indicating a high level of disease control 1. Infliximab is highly effective for maintaining remission in IBD, and discontinuing it could lead to disease flares and complications. The minor scalp psoriasis represents a paradoxical skin reaction that occasionally occurs with anti-TNF therapy like infliximab, and is typically manageable with topical treatments such as corticosteroid solutions, coal tar shampoos, or vitamin D analogs like calcipotriene for the scalp. Some key points to consider in the management of this patient include:

• The efficacy of infliximab in maintaining remission in IBD, as demonstrated by the ACCENT I trial and other studies 1
• The potential for psoriasis to be managed with topical treatments, as outlined in guidelines for the management of psoriasis and psoriatic arthritis 1
• The importance of monitoring the patient regularly to assess the severity of the psoriasis and the effectiveness of the treatment plan, as recommended by the British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults 1
• The potential for switching to a different biologic agent, such as ustekinumab, if the psoriasis becomes widespread or severely symptomatic despite topical management, although this would require careful consideration of the potential benefits and risks. Overall, the current treatment plan has been effective in maintaining remission in IBD, and the minor psoriasis can be managed with topical treatments, making it the best course of action to continue with the current treatment plan.

From the Research

Treatment Recommendations for IBD with Psoriasis

The patient in question has inflammatory bowel disease (IBD) in clinical and endoscopic remission, being treated with infliximab, and has developed minor psoriasis limited to the scalp. Considering the treatment options, the following points are relevant:

• Infliximab has demonstrated efficacy in both psoriasis and IBD, including Crohn's disease 2, 3.
• The development of psoriasis in this patient could be a paradoxical reaction to the anti-TNF therapy, but it is minor and limited to the scalp.
• Switching to another biologic agent such as adalimumab or ustekinumab could be considered, but there is no clear indication that this is necessary given the patient's current response to infliximab and the minor nature of the psoriasis.
• Adding another medication such as 6-mercaptopurine could be an option, but this would depend on various factors including the patient's overall health and the specific characteristics of their IBD and psoriasis.

Key Considerations

When deciding on the best course of action, the following factors should be taken into account:

• The patient's IBD is in remission, which suggests that the current treatment plan is effective for this condition.
• The psoriasis is minor and limited to the scalp, which may not necessitate a change in the IBD treatment plan.
• The potential risks and benefits of switching to a different biologic agent or adding another medication should be carefully considered.
• The patient's response to topical therapies for the psoriasis should be monitored, and adjustments made as necessary.

Potential Treatment Options

Based on the available evidence, the following treatment options could be considered:

• Continue with the current treatment plan, monitoring the patient's IBD and psoriasis closely for any changes.
• Consider adding a medication such as 6-mercaptopurine if the psoriasis worsens or if the patient's IBD begins to flare.
• Switch to a different biologic agent such as adalimumab or ustekinumab if the patient's IBD or psoriasis is not adequately controlled with infliximab.
• Continue to monitor the patient's response to topical therapies for the psoriasis, and adjust as necessary 2, 3, 4, 5, 6.