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 the current treatment plan of infliximab, as the benefits of maintaining IBD remission outweigh the risks of managing mild psoriasis. The development of minor psoriasis limited to the scalp, as a side effect of chronic anti-TNF therapy with infliximab, can be managed with topical treatments, and does not necessarily require a change in the IBD treatment plan. According to the ECCO guidelines on therapeutics in Crohn's disease 1, infliximab is effective for the induction and maintenance of remission in CD, and the patient has been in clinical and endoscopic remission with a Rutgeerts score of i1. The guidelines also suggest that combination therapy with a thiopurine can be de-escalated to anti-TNF monotherapy once long-term remission has been established, but this patient is already on infliximab monotherapy. The British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults 1 also recommend dose optimization for patients who have responded to anti-TNF therapy, but do not suggest switching to a different therapy unless there is a lack of response or significant side effects. In this case, the patient's psoriasis is minor and limited to the scalp, and can be managed with topical treatments, such as clobetasol 0.05% solution or fluocinonide 0.05% solution, as suggested by the guidelines for the management of psoriasis and psoriatic arthritis 1. Therefore, the current treatment plan of infliximab should be continued, with regular monitoring of the patient's IBD and psoriasis, and adjustments made as necessary to maintain remission and manage side effects. Some key points to consider in the management of this patient include:

• Regular dermatology follow-up to monitor the psoriasis and adjust topical treatments as necessary
• Monitoring of the patient's IBD activity and adjustment of the infliximab dose or addition of other therapies if necessary
• Consideration of the potential risks and benefits of switching to a different therapy, such as adalimumab or ustekinumab, if the patient's psoriasis worsens or becomes widespread.

From the FDA Drug Label

The provided drug labels do not directly address the management of a patient with inflammatory bowel disease (IBD) in clinical and endoscopic remission, being treated with infliximab, who develops minor psoriasis limited to the scalp.

The FDA drug label does not answer the question.

From the Research

Treatment Recommendations for IBD Patient with Psoriasis

The patient in question has fistulizing ileal Crohn's disease and has been on infliximab since 2010, with a current dose of 10 mg/kg every 8 weeks. She has developed minor psoriasis limited to the scalp, which is being treated with topical therapies. Considering her clinical and endoscopic remission, the following points are relevant to her treatment plan:

• The development of psoriasis in patients with inflammatory bowel disease (IBD) is not uncommon, and several treatments can be used to manage both conditions simultaneously 2, 3.
• Infliximab, a chimeric monoclonal antibody against tumor necrosis factor alpha (TNF-α), has demonstrated efficacy in treating both psoriasis and IBD, including Crohn's disease and ulcerative colitis 2, 3, 4.
• Given the patient's stable condition and the fact that her psoriasis is minor and limited to the scalp, there is no strong indication to switch her from infliximab to another medication like adalimumab or ustekinumab at this time.
• The efficacy and safety of infliximab in IBD patients have been well-documented, with studies showing significant reductions in disease activity indices and C-reactive protein levels 4.
• While adalimumab is also an effective treatment for IBD and psoriasis, comparative studies suggest that infliximab dose escalation may be more effective in maintaining treatment response in patients with IBD 5.

Considerations for Treatment Adjustment

Based on the available evidence, the following considerations apply to the patient's treatment plan:

• Continuing the current treatment plan with infliximab is a viable option, given the patient's clinical and endoscopic remission and the minor nature of her psoriasis 2, 3, 4.
• Adding 6-mercaptopurine to the patient's treatment regimen is not indicated at this time, as there is no evidence to suggest that her current treatment is insufficient or that she would benefit from combination therapy.
• Switching to adalimumab or ustekinumab is not recommended, as the patient is stable on infliximab and there is no strong indication for a change in treatment 2, 3, 5.
• Close monitoring of the patient's condition and adjustment of her treatment plan as needed are essential to ensure optimal management of her IBD and psoriasis.