Infliximab Dosing for Vasculitis
Infliximab is NOT a first-line agent for vasculitis and should only be considered for refractory or relapsing disease at a dose of 3-5 mg/kg per infusion, given every 1-2 months, though current guidelines prioritize rituximab or cyclophosphamide over infliximab for standard treatment. 1
Current Guideline Recommendations
The most recent KDIGO 2024 guidelines for ANCA-associated vasculitis do not include infliximab as a recommended therapy for induction or maintenance treatment. 1 Instead, the guidelines recommend:
- First-line induction therapy: Rituximab (375 mg/m² weekly × 4 weeks) or cyclophosphamide (oral 2 mg/kg/day or IV 15 mg/kg at weeks 0,2,4,7,10,13) with glucocorticoids 1
- Maintenance therapy: Rituximab or azathioprine with low-dose glucocorticoids for 18 months to 4 years 1
- Refractory disease: Increase glucocorticoids, switch between rituximab and cyclophosphamide, or consider plasma exchange 1
Historical Use of Infliximab
When infliximab has been used for vasculitis (primarily in older literature), the dosing has been:
- 3-5 mg/kg per infusion 1
- Frequency: Every 1-2 months 1
- Initial loading: Some protocols used infusions at weeks 0,2, and 6, then every 8 weeks 2, 3, 4
The 2009 EULAR guidelines listed infliximab only as an alternative option for relapsing, refractory, or persistent disease, not as standard therapy. 1
Critical Caveats and Contraindications
Infliximab should NOT be used for giant cell arteritis. A phase II trial demonstrated that patients receiving infliximab (5 mg/kg) had higher rates of disease activity and lower remission rates compared to placebo. 1 This represents a clear contraindication.
Infliximab can paradoxically cause vasculitis. Case reports document hypersensitivity vasculitis with leukocytoclastic vasculitis occurring after infliximab administration, even after the first dose. 5 This limits its utility as a vasculitis treatment.
Clinical Context for Modern Practice
In contemporary practice, infliximab has been largely supplanted by rituximab for refractory ANCA-associated vasculitis. The evidence supporting infliximab consists primarily of small open-label studies from 2002-2004 showing:
- 88% remission rates in 32 patients with refractory disease 3
- Mean BVAS reduction from 12.3 to 0.3 by week 14 3
- However, 21% developed severe infections and 20% experienced disease flares despite continued therapy 3
For refractory ANCA-associated vasculitis in 2024-2025, rituximab (375 mg/m² IV weekly for 4 doses or 1000 mg on days 1 and 15) is the preferred alternative agent, not infliximab. 6
When Infliximab Might Be Considered
If infliximab is being considered (which should be rare), appropriate scenarios include:
- Refractory disease after failure of rituximab and cyclophosphamide 1, 2, 3
- Specific cases of Behçet's disease with severe ocular involvement (5 mg/kg at weeks 0,2,6, then every 8 weeks) 7
- Patients enrolled in clinical trials 1
The higher dose of 5 mg/kg appears more effective than 3 mg/kg for inducing remission in the limited available data. 4