Can infliximab (chimeric monoclonal antibody against tumor necrosis factor-alpha) and cyclosporin (cyclosporine, an immunosuppressant) be used together in treatment?

Infliximab and Cyclosporin Combination Therapy

Sequential use of infliximab and cyclosporin within 3 months is not recommended due to risks of profound immunosuppression and serious infections, though the two drugs can be used as alternative rescue therapies in acute severe ulcerative colitis. 1

Context-Specific Recommendations

Acute Severe Ulcerative Colitis (ASUC)

Choose one agent, not both:

• Infliximab and ciclosporin demonstrate equivalent efficacy as rescue therapy after steroid failure, with no statistically significant difference in treatment failure rates (54% vs 60%, respectively) 1, 2
• Both achieve similar mucosal healing rates (45% infliximab vs 47% ciclosporin) and colectomy rates (21% vs 17%) 1
• Sequential therapy (using the second agent within 3 months after the first) is specifically not recommended due to profound immunosuppression risks 1
• The ENEIDA registry showed sequential therapy used in only 10% of cases with median time between treatments of 24 days, though safety appeared comparable to monotherapy 1
• The greatest risk of sequential therapy is delaying necessary surgery in deteriorating patients 1

When infliximab is chosen for ASUC:

• Start azathioprine at day 7 in clinical responders, not cyclosporin 1, 3
• Combination of infliximab with azathioprine shows synergistic effects, raising infliximab levels and reducing antibody formation 1, 3

Rheumatoid Arthritis

Combination therapy is feasible but requires careful monitoring:

• Low-dose cyclosporin (2 mg/kg/day) combined with infliximab (3 mg/kg every 8 weeks) achieved 80% ACR20 response in patients who could not tolerate methotrexate 4
• This combination showed 76% reduction in swollen and tender joint counts with maintained reduction in inflammatory markers 4
• Treatment was generally well tolerated with minimal adverse reactions, though one patient developed pulmonary tuberculosis 4
• This combination should only be considered when methotrexate cannot be used, as methotrexate remains the preferred combination agent with infliximab 1, 5

Behçet's Syndrome

Combination use is debated without clear benefit:

• Some experts suggest concomitant use of cyclosporine-A with monoclonal anti-TNF antibodies may improve outcomes in refractory uveitis 1
• However, a retrospective case series showed concomitant use of these agents did not provide extra benefit 1
• Plasma concentrations of cyclosporine-A may be reduced by co-administration with azathioprine, requiring careful monitoring 1

Other Dermatologic Conditions

Limited evidence supports combination use:

• Case reports describe successful use of infliximab in patients with refractory inflammatory dermatoses previously treated with cyclosporine, but not concurrent use 6, 7
• For psoriasis, case series suggest etanercept may be combined with cyclosporine short-term to improve efficacy, but long-term safety is unknown 1

Critical Safety Considerations

Infection risk is substantially elevated:

• Both agents are potent immunosuppressants that increase risk of serious infections including tuberculosis, Pneumocystis jirovecii pneumonia, and opportunistic infections 1
• Prophylaxis for Pneumocystis jirovecii should be given when combining immunosuppressants 1
• Tuberculosis screening with purified protein derivative or QuantiFERON is mandatory before infliximab 1, 8

Monitoring requirements when combination is unavoidable:

• More frequent complete blood count monitoring to detect neutropenia 1, 3
• Liver function tests every 6-12 weeks 1, 3
• Renal function monitoring for cyclosporine nephrotoxicity 1
• Assessment for infections before each infliximab infusion 8

Practical Algorithm for Decision-Making

For ASUC refractory to steroids:

1. Choose either infliximab OR cyclosporin based on center experience and patient factors (tuberculosis risk, tolerability) 1
2. If first agent fails, consider surgery before sequential therapy 1
3. If sequential therapy attempted, ensure minimum 24 days between agents and close surgical consultation 1

For rheumatoid arthritis:

1. First-line: infliximab + methotrexate 1, 5
2. If methotrexate contraindicated: consider infliximab + low-dose cyclosporin (2 mg/kg/day) 4
3. Monitor closely for infections and tuberculosis reactivation 4

For other conditions:

1. Use infliximab OR cyclosporin as monotherapy 6, 7
2. Avoid concurrent use unless absolutely necessary with expert consultation 1