What is the recommended treatment for a 45-year-old gentleman with chronic bloody diarrhea, abdominal pain, fecal incontinence, and significant weight loss, diagnosed with inflammatory bowel disease (IBD) unresponsive to steroids, mesalazine (Mesalamine), and antibiotics, with findings of colonic wall thickening, severely inflamed mucosa, and minimal mucosal inflammatory infiltrate?

From the Guidelines

I strongly recommend infliximab as the next line of treatment for this patient. The patient's clinical presentation and history suggest a severe case of inflammatory bowel disease (IBD) that has been refractory to multiple medical therapies, including corticosteroids, mesalazine, and antibiotics 1. The symptoms of bloody diarrhea, abdominal pain, fecal incontinence, and significant weight loss over 10 months indicate a progressive disease process that requires more aggressive treatment.

The CT findings showing wall thickening in the descending colon, sigmoid, and rectum, along with the endoscopic findings of severely inflamed mucosa with cobblestone appearance, are consistent with IBD 1. The biopsy findings of minimal mucosal inflammatory infiltrate with atrophic crypts and prominent musculized capillaries with fibrin thrombi suggest a chronic inflammatory process that may benefit from biologic therapy.

Infliximab, an anti-TNF agent, is a well-established treatment for IBD, particularly for patients who have failed conventional immunosuppressive therapies 1. The introduction of biosimilars has made infliximab a more accessible and cost-effective option for patients. Given the patient's severe symptoms and lack of response to previous treatments, infliximab is a reasonable next step in management.

It is essential to note that surgery may still be required in the future, but given the current evidence, infliximab should be tried first to induce remission and prevent further disease progression 1. The patient should be closely monitored for response to treatment and potential side effects, and adjustments to the treatment plan can be made as needed.

Some key points to consider in the management of this patient include:

• The importance of multidisciplinary care, involving gastroenterologists, surgeons, and other specialists as needed 1
• The need for regular monitoring of disease activity and adjustment of treatment plans accordingly 1
• The potential benefits and risks of biologic therapy, including infliximab, and the importance of patient education and informed decision-making 1

From the Research

Treatment Options for Ulcerative Colitis

The patient presents with symptoms of ulcerative colitis, including bloody diarrhea, abdominal pain, fecal incontinence, and significant weight loss. Given the patient's lack of response to conventional therapies such as steroids, mesalazine, and antibiotics, consideration of alternative treatment options is necessary.

Biologic Therapies

• Infliximab is a biologic agent that has been shown to be effective in treating moderate to severe ulcerative colitis, particularly in patients who have failed conventional therapies 2, 3.
• The use of infliximab as a first-line biologic therapy may be beneficial in achieving complete mucosal healing, steroid-free remission, and improved quality of life 2.
• However, in patients who have failed infliximab, vedolizumab may be a suitable alternative, with some studies suggesting superior efficacy and safety compared to infliximab in this population 4, 5.

Treatment Sequencing

• The sequencing of biologic therapies, including infliximab and vedolizumab, may impact long-term outcomes in patients with ulcerative colitis 6.
• A study comparing infliximab-first and vedolizumab-first treatment strategies found no significant difference in hospitalizations, corticosteroid courses, and serious infections between the two groups 6.

Recommendations

Based on the available evidence, the following treatment options may be considered:

1. Infliximab: Given the patient's lack of response to conventional therapies, infliximab may be a suitable option for inducing and maintaining remission 2, 3.
2. Vedolizumab: If the patient has failed infliximab or is considered a candidate for vedolizumab, this biologic agent may be a viable alternative 4, 5.
3. Surgery: In patients with severe disease or those who have failed multiple biologic therapies, surgical resection of the affected areas of the colon and rectum may be necessary.
4. Other treatment options: Isozionide, rifampin, and ethambutol are not typically used in the treatment of ulcerative colitis, and their use in this context is not supported by the available evidence. Corticosteroids and cyclophosphamide may be considered in certain situations, but their use should be guided by clinical judgment and evidence-based practice.