Case 10: 30-year-old male requiring an anti-TNF (a biologic)
VISIT 1 First visit to the gastroenterologist
30-year-old male has had ulcerative colitis involving his entire colon for 6 years. The initial treatment was with oral prednisone and Imuran
Since the initial flare the patient has continued on Imuran.
For 3 months the patient has been feeling very unwell – having 6 bloody bowel movements daily (including 1 bowel movement most nights). He is not having any fevers and has not lost any weight.
The doctor orders blood and stool tests, and books a flexible sigmoidoscopy
VISIT 2 At the flexible sigmoidoscopy 4 weeks later
The results of the blood tests shows a low hemoglobin and a normal CRP (a blood test which suggests inflammation).
The flexible sigmoidoscopy shows moderately-active inflammation.
The diagnosis: active ulcerative colitis
The treatment: prednisone 40mg orally for 2 weeks, followed by a tapering course of 5mg per week.
VISIT 3 Gastroenterology visit 2 weeks later
The patient was instructed that if he got worse during those 2 weeks he needed to call his doctor.
1 week into prednisone use the patient was feeling worse. He was getting up multiple times during the night and there was more blood with each bowel movement.
There were two options given:
1. Admission to hospital to receive intravenous corticosteroids, or;
2. Begin an anti-TNF medication (Remicade, Humira, or Simponi)
To prepare for the possibility of starting an anti-TNF medication, the patient got a TB skin test and a chest X-ray (to ensure the patient has never had TB in the past).
VISIT 4 1 week later the decision was made to start on Humira
The patient took another 1 week of prednisone 40mg and began to taper off this medication. He continued on Imuran and began Humira.
The first dose of Humira was 4 injections followed by 2 injections 2 weeks later, and then 1 injection every 2 weeks (some patients require higher doses which usually means 1 injection each week).
VISIT 5 2 month later: follow up appointment with gastroenterologist
The patient is doing well: his bowel routine is almost normal, no longer seeing any blood and the urgency is no longer present
The patient is no longer taking prednisone, but continues on both Imuran and Humira
The doctor reinforces the importance of continuing to take his current medication. He orders bloodwork which comes back as all normal except for evidence of mild iron deficiency. The patient is placed on oral iron supplement
The important feature of this management plan is that when things don’t go as planned (the patient got worse on oral prednisone), there is an immediate communication between the patient and their physician. Furthermore action was taken appropriately to respond to evidence of the flare worsening.
The combination of Imuran with an anti-TNF medication (Remicade, Humira or Simponi) can be considered in patients who don’t respond to prednisone.