Case 20.1

Submitted by Rishika Chugh, MD

A 79-year-old woman with a history of rheumatoid arthritis was diagnosed with stricturing ileocolonic Crohn’s disease 20 years ago during exploratory laparotomy. No bowel was resected at this time. She was treated with methotrexate, pentasa, and steroids for many years. She was ultimately switched to infliximab with good response for 6-7 years but then had secondary loss of response in the setting of antibody development. She was transitioned to certolizumab along with azathioprine but then developed pneumonitis leading to an ICU admission. Certolizumab was discontinued. Following her recovery, she was started on adalimumab 40mg every 2 weeks along with azathioprine. Unfortunately, she had suboptimal response to this despite adequate levels.

She now presents for follow up with you and continues to have symptoms. What would be your next recommendation?
Ustekinumab
Considering her age, ICU admission for infectious complication, and prior trial of three different anti-TNFs (infliximab, adalimumab, and certolizumab), it would be reasonable to consider a medication from a different class in this situation. Prior meta-analyses have indicated that in moderate to severe Crohn’s disease patients with prior TNF exposure, adalimumab and ustekinumab ranked the highest for induction of clinical remission. For this reason, Ustekinumab is the most reasonable option for her Crohn’s disease, realizing that it will not help her rheumatoid arthritis and she may need a different therapy for her RA.
Dual biologic/ small molecule therapy
Dual biologic and small molecule therapy can be considered in the future if the patient were to fail monotherapy with ustekinumab.
Re-challenge with infliximab
Her history of ICU admission for infectious complications makes rechallenge with infliximab less ideal. Additionally, given she had antibodies to infliximab as the reason for discontinuation, she is less likely to tolerate a re-challenge.
Switch to golimumab
Her history of ICU admission for infectious complications as well as her age and prior anti-TNF failure makes treatment with a different drug in the same class less ideal. n addition, golimumab is not FDA approved for Crohn’s disease

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