Question

AK, a 27-year-old Caucasian female returns to her PCP for a follow-up visit about her Crohn disease. She has struggled to gain control of her CD despite treatments with Asacel prednisone, and mercaptopurine. She was recently diagnosed with enterocutaneous fistulas as a complication of her CD. This has become a significant disturbance in her life in addition to her refractory CD, and she would like another treatment that may assist her overall condition.

Allergies: NKDA
Medications: Asacol 800mg3 tabs po daily; prednisone 20mg tablet 1 po daily; mercaptopurine 50mg tablet 2 po daily
Physical Exam/Other Studies: Wt 142lb Ht 68 in T 98.6
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F BP 126/82 HR 84 RR 14O
2
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sat 99% Physical exam reveals evidence of perianal fistulas. The physician has decided to initiate infliximab for this patient. Which of the following are important to discuss with the patient prior to start of therapy? (Select ALL that apply)
A. Infliximab can be self-administered as IM or SC
B. Rule out tuberculosis prior to the start of therapy
C. Patient must pre-medicate with diphenhydramine and Tylenol prior to the administration of infliximab to decrease the incidence of infusion reactions
D. Pancreatic enzymes must be monitored with this drug
E. Humira may be added to infliximab for better efficacy and control of her fistulas

Answer 1

Prior to starting infliximab therapy, it is important to explain that the drug is administered intravenously, to rule out tuberculosis, discuss the potential for pre-medication with diphenhydramine and Tylenol to reduce infusion reactions, and understand that Humira should not be added due to risks of combining TNF-alpha inhibitors.

Step-by-step explanation:

Before starting infliximab therapy for Crohn's disease, it is important to discuss several considerations with the patient. Infliximab is not self-administered and is given as an intravenous (IV) infusion, not intramuscularly (IM) or subcutaneously (SC). It is critical to rule out tuberculosis (TB) before initiating infliximab because it can reactivate latent TB due to its immunosuppressive action.

While pre-medication with diphenhydramine and Tylenol (acetaminophen) isn't always necessary, many patients do pre-medicate to decrease the incidence of infusion reactions; this should be discussed with the healthcare provider. Monitoring pancreatic enzymes is not routinely required for patients on infliximab.

Lastly, the combination of Humira (adalimumab) and infliximab is generally not recommended due to increased risks without proven increased efficacy. Both drugs are TNF-alpha inhibitors and using them together can increase the risk of serious infections and other side effects. Each of these points should be thoroughly explained to the patient to ensure they are fully informed about their treatment options.