From the Guidelines
For a patient with Crohn's disease on Remicade (infliximab) who is newly diagnosed with influenza, I recommend temporarily holding the Remicade infusion until the influenza infection resolves. Start antiviral therapy with oseltamivir (Tamiflu) 75 mg orally twice daily for 5 days, ideally within 48 hours of symptom onset, as suggested by the Infectious Diseases Society of America guidelines 1. Provide supportive care including acetaminophen for fever and pain (avoid NSAIDs as they may exacerbate Crohn's disease), adequate hydration, and rest. Monitor the patient closely for respiratory complications or worsening of Crohn's symptoms.
Key Considerations
- The patient's immunosuppressed state due to Remicade therapy may increase the risk of complications from influenza, making prompt antiviral treatment crucial 1.
- The British Society of Gastroenterology consensus guidelines suggest that combination therapy with infliximab and an immunomodulator may be beneficial in reducing immunogenicity and improving treatment outcomes in Crohn's disease patients 1.
- The Canadian Association of Gastroenterology clinical practice guideline recommends against the use of systemically absorbed antibiotics to induce or maintain complete remission in Crohn's disease patients, unless there is a clear indication for their use 1.
Management Plan
- Temporarily hold Remicade infusion until influenza infection resolves
- Start antiviral therapy with oseltamivir (Tamiflu) 75 mg orally twice daily for 5 days
- Provide supportive care and monitor for complications
- Resume Remicade therapy after influenza infection has resolved, typically after 7-10 days
- Consider influenza vaccination (if not already done) for future seasons, ideally timed between Remicade doses to optimize vaccine response 1.
From the Research
Management of Crohn's Disease
- The optimal management approach for Crohn's disease incorporates patient risk stratification, patient preference, and clinical factors in therapeutic decision-making 2.
- First-line therapy generally consists of steroids for rapid palliation of symptoms during initiation of anti-tumor necrosis factor α therapy, such as infliximab 2, 3.
Treatment with Infliximab
- Induction therapy with infliximab is indicated for treatment of signs and symptoms, and induction and maintenance of remission in patients with moderate to severely active inflammatory Crohn's disease with an inadequate response to conventional therapy 3.
- The combination of infliximab and azathioprine has been shown to be effective in inducing and maintaining remission in patients with Crohn's disease 4, 5, 6.
Management of Influenza in Patients with Crohn's Disease
- Vaccinations to prevent infections, such as influenza, pneumonia, and herpes zoster, are important components of health maintenance for patients with Crohn's disease, although live vaccines are contraindicated for patients receiving immune suppression therapy 2.
- There is no direct evidence on the management of influenza in patients with Crohn's disease on remicade, but it is recommended to follow general guidelines for managing influenza in immunocompromised patients.
Considerations for Patients on Immunosuppressive Therapy
- Patients with evidence of active infection should not receive infliximab until the infection is adequately treated 3.
- Concomitant immunosuppressive therapy with azathioprine, 6-mercaptopurine, or methotrexate may result in improved outcomes due to a reduction in the frequency of human anti-chimeric antibody formation, acute infusion reactions, and a reduced risk of delayed hypersensitivity-like reactions and formation of antinuclear antibodies 3.