Infliximab Dosing for Behçet's Disease
For Behçet's disease, infliximab should be administered at 5 mg/kg intravenously at weeks 0,2, and 6, followed by maintenance infusions every 6-8 weeks, with interval adjustments based on individual response. 1
Standard Induction Dosing
- Initiate infliximab at 5 mg/kg IV at weeks 0,2, and 6 for all manifestations of Behçet's disease requiring anti-TNF therapy 1, 2, 3
- This induction schedule mirrors the established dosing for other inflammatory conditions and has demonstrated efficacy in severe Behçet's manifestations 1
Maintenance Dosing Strategy
Standard Maintenance
- Continue infusions every 8 weeks at 5 mg/kg after the induction phase 2, 4, 5
- This interval has been validated in multiple prospective studies of Behçet's uveitis and systemic disease 4, 5
Dose Optimization for Inadequate Response
- Shorten infusion intervals to every 6 weeks if breakthrough disease activity occurs on standard 8-week dosing 2, 5
- In one prospective study, 2 of 10 patients with Behçet's uveitis required interval reduction to 6 weeks to maintain remission 2
- Alternatively, increase dose to 10 mg/kg while maintaining 8-week intervals, though this is less commonly employed in Behçet's disease compared to interval shortening 1
Disease-Specific Considerations
Ocular Behçet's Disease
- The 2018 EULAR guidelines recommend monoclonal anti-TNF antibodies (including infliximab) for posterior segment uveitis, with the standard 5 mg/kg dosing regimen 1
- Long-term studies demonstrate sustained efficacy with 68% complete response rates using standard dosing every 8 weeks 4
- Visual acuity improvements are typically evident by 2 months and maintained with continued therapy 5
Severe Vascular or Neurological Behçet's
- A recent 2024 phase 2 RCT established infliximab 5 mg/kg at weeks 0,2,6,12, and 18 as superior to cyclophosphamide for severe Behçet's syndrome with major vascular or CNS involvement 3
- This regimen achieved 81% complete response rates versus 56% with cyclophosphamide, with fewer adverse events 3
- EULAR guidelines recommend monoclonal anti-TNF antibodies for refractory vascular and arterial involvement 1
Gastrointestinal Behçet's Disease
- Standard dosing of 5 mg/kg every 8 weeks is effective for intestinal Behçet's disease refractory to conventional therapy 6
- At 10 weeks, 80% of patients showed clinical response with this regimen 6
Critical Monitoring Requirements
Pre-Treatment Screening
- Mandatory tuberculosis screening with PPD or interferon-gamma release assay before initiating infliximab 1
- Hepatitis B and C screening required 1
- Baseline CBC, liver function tests, and hepatitis profile 1
Ongoing Surveillance
- Periodic history and physical examination while on treatment 1
- Consider yearly PPD and periodic CBC and liver function tests 1
- Monitor for infusion reactions, which may be reduced by concurrent methotrexate administration 1
Common Pitfalls to Avoid
- Do not use intermittent or "as-needed" dosing: Continuous scheduled therapy reduces antibody formation and maintains superior efficacy compared to episodic treatment 1
- Do not delay interval shortening in patients with breakthrough attacks: Studies show that patients requiring more frequent dosing benefit from proactive adjustment to 6-week intervals rather than waiting for multiple relapses 2, 5
- Do not exceed 5 mg/kg dosing in patients with NYHA class III or IV heart failure, as higher doses are contraindicated 1
- Fulminant intestinal disease may predict poor response: Consider alternative or combination therapy in this subset 6
Combination Therapy Considerations
While combination with immunosuppressives like azathioprine or methotrexate reduces immunogenicity in other conditions 1, the evidence for mandatory combination therapy in Behçet's disease is less established. However, concurrent immunosuppression may be considered to reduce antibody formation, particularly in patients requiring long-term therapy 1.