Can Infliximab Be Given to a Patient on Hydrocortisone?
Yes, infliximab can be safely administered to patients on hydrocortisone, and in fact, hydrocortisone premedication is commonly used to reduce infusion reactions and antibody formation to infliximab. 1, 2
Evidence Supporting Concurrent Use
Hydrocortisone as Premedication
Hydrocortisone premedication (100-200 mg IV) given 20-30 minutes before infliximab infusion significantly reduces antibody formation to infliximab (ATI) and decreases the risk of infusion reactions. 1, 2
In a randomized controlled trial, intravenous hydrocortisone 200 mg given before infliximab infusions significantly reduced ATI levels (1.6 vs. 3.4 µg/mL, P = 0.02) and decreased ATI formation rates (26% vs. 42%, P = 0.06) compared to placebo. 2
Studies in inflammatory bowel disease patients show that premedication with 100 mg IV hydrocortisone plus antihistamines resulted in only 6% of patients experiencing infusion reactions, with reactions occurring in only 1.4% of all infusions. 3
Clinical Practice Protocols
For patients with severe hypersensitivity reactions to infliximab, the recommended premedication protocol includes prednisone 50 mg PO × 3 doses over 12 hours before infusion, or hydrocortisone 100 mg IV, or methylprednisolone 2-40 mg IV given 20 minutes before infusion. 1
The protocol then involves starting the infliximab infusion at 10 mL/h for 15 minutes, with gradual rate increases if tolerated. 1
Therapeutic Context: Infliximab WITH Corticosteroids
Immune Checkpoint Inhibitor Toxicity Management
Infliximab is specifically recommended as second-line therapy for immune checkpoint inhibitor (ICI) colitis that fails to respond to corticosteroids within 72 hours to 1 week. 1
For grade 2 ICI colitis with no improvement after 3-5 days of oral corticosteroids (1 mg/kg), infliximab 5 mg/kg should be administered. 1
For steroid-refractory ICI enterocolitis, infliximab is typically dosed at 5 mg/kg IV at weeks 0,2, and 6, with responses occurring rapidly (usually within 1 week). 1
Important Caveats for Infliximab Use
Infliximab should be used with caution in patients with ICI hepatitis due to potential risk of idiosyncratic liver toxicity. 1
The decision to use infliximab in patients with both ICI hepatitis and enterocolitis should be made on a case-by-case basis, as infliximab can induce a rare form of hepatitis. 1
Infliximab should be avoided in patients with underlying hematologic malignancies due to association with rare lymphomas, and used cautiously in severe congestive heart failure. 1
Long-term Considerations
In patients with sustained clinical remission on maintenance infliximab therapy for at least 6 months, hydrocortisone premedication can be safely discontinued without increased risk of antibody formation or infusion reactions. 4
A prospective study of 95 IBD patients showed no development of permanent ATIs or infusion reactions at 1 year after hydrocortisone withdrawal in patients with prolonged remission. 4
Bottom Line
There is no contraindication to giving infliximab while a patient is on hydrocortisone. In fact, hydrocortisone is routinely used as premedication to enhance the safety profile of infliximab infusions, particularly for patients at higher risk of infusion reactions. 1, 2, 3 Additionally, infliximab is frequently used as rescue therapy for patients already receiving high-dose systemic corticosteroids who have failed to respond adequately. 1