alexa Induction of Remission and Maintenance Therapy with Tacrolimus in Refractory Ulcerative Colitis with Adverse Events from 5-ASA and Thiopurine | Open Access Journals
ISSN: 2165-7920
Journal of Clinical Case Reports
Make the best use of Scientific Research and information from our 700+ peer reviewed, Open Access Journals that operates with the help of 50,000+ Editorial Board Members and esteemed reviewers and 1000+ Scientific associations in Medical, Clinical, Pharmaceutical, Engineering, Technology and Management Fields.
Meet Inspiring Speakers and Experts at our 3000+ Global Conferenceseries Events with over 600+ Conferences, 1200+ Symposiums and 1200+ Workshops on
Medical, Pharma, Engineering, Science, Technology and Business

Induction of Remission and Maintenance Therapy with Tacrolimus in Refractory Ulcerative Colitis with Adverse Events from 5-ASA and Thiopurine

Ayumi Ito*

Institute of Gastroenterology, Tokyo Women’s Medical University, Japan

*Corresponding Author:
Ayumi Ito
Institute of Gastroenterology
Tokyo Women’s Medical University, Japan
Tel: +81-3-3353-8111
Fax: +81-3-5269-7507
E-mail: itoayumi.ige@twmu.ac.jp

Received Date: June 04, 2017; Accepted Date: June 20, 2017; Published Date: June 26, 2017

Citation: Ito A (2017) Induction of Remission and Maintenance Therapy with Tacrolimus in Refractory Ulcerative Colitis with Adverse Events from 5-ASA and Thiopurine. J Clin Case Rep 7:974. doi: 10.4172/2165-7920.1000974

Copyright: © 2017 Ito A. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Visit for more related articles at Journal of Clinical Case Reports

Abstract

A 58-year-old Japanese woman was admitted to the hospital with fever, diarrhea, melena and lower abdominal pain. Colonoscopy showed moderate left-sided Ulcerative Colitis (UC). Administration of 5-aminosalicylic acid (5- ASA) (3600 mg) was started, but skin eruptions and hepatic dysfunction occurred. The drug lymphocyte stimulation test (DLST) was positive for 5-ASA, so this medication was discontinued. Prednisolone (PSL, initially 10 mg/day) was started, and remission was achieved. However, relapse occurred 5 months later after the discontinuation of PSL, and hospitalization was required again. Remission was achieved again by PSL, and azathioprine (AZA) (initially 25 mg/day) was started as maintenance therapy. Hepatic dysfunction was detected at 1 month after starting AZA and was judged to represent drug-induced hepatitis. Following the discontinuation of AZA, PSL (2 mg/day) monotherapy was continued. At 11 months after discharge from hospital, the patient developed diarrhea, melena, and abdominal pain, requiring hospitalization for the third time. Colonoscopy showed extensive ulceration and spontaneous bleeding, indicating a relapse of severe UC. Administration of tacrolimus (TAC) led to remission and the patient was discharged from hospital. Because she experienced adverse effects with 5-ASA and AZA, TAC alone was continued as maintenance therapy for ≥ 2 years after the discontinuation of PSL. Relapse did not occur during this period and repeat colonoscopy showed mucosal healing. During the TAC maintenance therapy, slight deterioration of renal function was observed, but there were no other adverse events. In conclusion, we experienced a rare patient who responded to TAC maintenance monotherapy for severe UC.

Keywords

Ulcerative colitis; Tacrolimus; Remission; Tacrolimus maintenance therapy

Introduction

Ulcerative colitis (UC) is a chronic inflammatory bowel disease with remissions and relapses. Tacrolimus (TAC) and biological agents for refractory UC have recently broadened the options for remission induction therapy. TAC in particular has been reported to achieve a high remission rate in patients with refractory UC (1). However, it is unclear whether TAC is effective as maintenance therapy.

We treated a patient with UC for whom the maintenance of remission was difficult to achieve, due to her associated adverse reaction to common medications used for maintenance therapy. The patient has maintained long-term remission on TAC monotherapy as of the time of this writing, 3 years after the initiation of the TAC monotherapy. We report this case and provide a brief literature review.

Case Report

The patient was a 58-year-old Japanese woman whose extensive UC had been diagnosed 1 year prior to her first visit to our hospital with fever (temperature>38°C), diarrhea (6–7 times/day), melena (3–4 times/day), and lower abdominal pain. She was diagnosed with moderate left-sided UC by colonoscopy/histopathology and was admitted to the hospital due to persistent fever (>38°C). After admission, 5-ASA (3600 mg/day) was started, but a few days later eruptions appeared on her neck, and liver function tests showed elevated values. A Drug Lymphocyte Stimulation Test (DLST) was positive for 5-ASA, and we therefore discontinued this drug. Administration of prednisolone (PSL, 10 mg/day) was started, but it did not improve the diarrhea, melena and abdominal pain. In addition, bilateral knee pain and coin-shaped erythema nodosum on both lower extremities were noted at 10 days after admission. These symptoms were considered extra intestinal complications of UC, so PSL was increased to 40 mg/day. After this dosage increase, the diarrhea, melena, abdominal pain, fever, and joint pain improved rapidly. PSL was gradually tapered to 20 mg/day, and the patient was discharged from hospital. Three months later, the administration of PSL was discontinued and the patient received no other therapy. Two months after the discontinuation of PSL, diarrhea (8–9 times/day), melena (5–6 times/day), and lower abdominal pain appeared again.

She was admitted to our hospital a second time with a relapse of UC. Colonoscopy showed moderate UC (Figure 1), and thus she was treated with 30 mg/day PSL. This resulted in an immediate improvement of clinical signs and symptoms, and the administration of azathioprine (AZA, 25 mg/day) was started as maintenance therapy 2 weeks later. Since no adverse effects were observed, the dosage of AZA was increased to 50 mg/day and the patient was discharged from the hospital. At 1 month after the start of AZA therapy, liver dysfunction was detected (T-bil, 0.8 mg/dL; D-bil, 0.1 mg/dL; AST, 117 U/l; ALT, 165 U/l; ALP, 2381 U/l; γ-GTP, 2420 U/L; and PT>100%). Tests for autoantibodies and markers of hepatitis virus B and C were negative. The latter changes were considered to be due to drug-induced hepatitis, and the AZA was therefore discontinued. The liver function improved after the discontinuation of AZA. PSL was gradually tapered to 2 mg/day by 8 months after the start of its administration. Although we recommended treatment with a biological agent during the gradual tapering of PSL, the patient refused such therapy. Therefore, the administration of PSL (2 mg/day) was continued.

clinical-case-reports-Pre-treatment

Figure 1: Pre-treatment colonoscopic findings as far as the transverse colon.

At 11 months after the second discharge, the patient’s UC relapsed with abdominal pain, diarrhea, and melena. She was admitted to our hospital for a third hospitalization. The findings included height of 158 cm, weight 46 kg, blood pressure 122/72 mmHg, and pulse rate 70/min. The body temperature was 36.8°C. The stool frequency was 8–10 times/ day and the frequency of melena was 4–5 times/day, with no defecation at night.

The physical examination showed redness of the skin with no swelling. The abdomen was flat and soft, with moderate tenderness in the sub-umbilical region. Laboratory tests showed Hb of 11.3 g/ dL (anemia), and the white blood cell count was increased to 9180/μl, though the platelet count was increased to 529,000/μl. Biochemical tests showed a decrease in serum albumin to 2.8 mg/dL, with the CRP of 1.07 mg/dL, and high levels of certain inflammatory parameters. Coagulation tests showed an increase in D-dimer (up to 1.4 μg/mL). A stool culture showed normal bacterial flora only (Table 1).

Laboratory findings Values Units
WBC count 9.18×103 μL
Neutrophils, % 77.2 %
Lymphocytes, % 16.8 %
Hemoglobin 11.3 g/dL
Platelet count 52.9×104 μL
Coagulation factors
Prothrombin time % 100 %
D-dimer 1.4 μg/mL
Biochemical tests
TP 6.5 g/dL
ALB 2.8 g/dL
T-Bil 0.3 mg/dL
AST 17 U/l
ALT 11 U/l
ALP 206 U/l
γGTP 37 U/l
LD 168 U/l
BUN 9.1 mg/dL
Cre 0.65 mg/dL
eGFR 71.6 ml/min
Na 142 mEq/L
K 4.1 mEq/L
CL 102 U/l
TG 141 mg/dL
HDL 44 mg/dL
CRP 1.07 mg/dL
Infection
CMVAgC7-HRP (−) --
T-SPOT.Tb (−) --
Stool culture (−) --

Table 1: Laboratory findings on admission.

Colonoscopy findings: A colonoscope was inserted to the cecum. Deep ulceration, severe mucosal edema, and easy bleeding on contact with the scope were observed from the transverse colon (a) to the sigmoid colon. Mucosal edema, small ulcers, and adhesions of mucosa were observed in the rectum (Figure 1).

After the third admission: Based on the colonoscopy findings of severe mucosal edema, deep ulceration, and easy bleeding in the left colon, we diagnosed a relapse of severe UC. A central venous catheter was inserted, and we initiated a nil oral regimen. Treatment with PSL (30 mg/day) and TAC blood trough (10-15 ng/mL) was started. The TAC trough level was high at 2 days after the start of the administration, and the Lichtiger score (for the clinical evaluation of the severity of UC) was 4 at 7 days after the start of TAC therapy, indicating that remission was achieved [1,2].

Colonoscopy was repeated 15 days after the start of TAC administration. The mucosal edema and easy bleeding had improved, and a regression of ulceration and mucosal healing in the ulcer bases was observed (Figure 2). These findings suggested a complete response to the TAC. Accordingly, oral intake of food was started and the PSL was decreased by 10 mg every week. The patient was discharged from the hospital at 30 days after starting TAC, by which time the PSL dose had been decreased to 10 mg/day. Colonoscopy was performed again 3 months after the start of TAC therapy and showed mucosal healing (Figure 3), confirming the induction of remission by the TAC. The administration of TAC was continued, and the PSL was gradually tapered and discontinued. Maintenance therapy with TAC alone was continued for 3 years. During this period, relapse did not occur and colonoscopy continued to show mucosal healing (Figures 4 and 5). During maintenance therapy with TAC blood trough (5-10 ng/mL) alone, mild renal dysfunction was observed, but there were no other adverse effects (Figure 6).

clinical-case-reports-Colonoscopic-findings

Figure 2: Colonoscopic findings at 2 weeks after the start of TAC treatment.

clinical-case-reports-Colonoscopic-findings

Figure 3: Colonoscopic findings at 12 weeks after the start of TAC treatment.

clinical-case-reports-Colonoscopic-findings

Figure 4: Colonoscopic findings at 24 weeks after the start of the treatment.

clinical-case-reports-Colonoscopic-findings

Figure 5: Colonoscopic findings at 96 weeks after the start of the TAC treatment.

clinical-case-reports-TAC-blood

Figure 6: Serial changes in the TAC blood trough, serum creatinine, and eGFR.

Discussion

The treatment of UC is selected based on its clinical and endoscopic severity, as well as the therapeutic response to PSL (3). In our patient, 5-ASA was used during the initial treatment, but allergy and hepatic dysfunction occurred. Subsequently, remission was achieved with PSL alone, but relapse occurred after the discontinuation or decrease of PSL. Remission was achieved again after resuming treatment with PSL, and thus an administration of AZA was started as maintenance therapy [3,4]. However, hepatic dysfunction occurred after the AZA was started, and thus we discontinued it and the patient’s liver dysfunction resolved spontaneously. PSL monotherapy was started subsequently but relapse occurred. The second relapse was severe both clinically and endoscopically. Therefore, TAC add-on therapy was used for the steroid-dependent refractory UC [4,5].

AZA could not be used because the patient showed signs of allergic reactions. Therefore, after the induction of remission with TAC, we considered maintenance therapy with a biological agent [6]. However, the patient had several drug allergies and she was anxious about using a new medication, which made it difficult to start the use of a biological drug. In addition, she had no allergic reaction to TAC and no adverse events were observed. Accordingly, we used TAC as the maintenance therapy. During the maintenance therapy with TAC, only minor renal dysfunction was observed. The trough levels of TAC and the changes of renal function are shown in (Figure 6).

In this patient, no adverse effects apart from minor renal dysfunction were observed during the long-term administration of TAC. This suggested the possible safety of the long-term use of this drug [7].

Several studies have reported that TAC achieves a high remission rate when used for remission induction therapy in patients with severe refractory UC. Generally, AZA is used to maintain the remission of UC after remission induction by TAC [3,4,8]. However, it has been reported that in patients with adverse effects due to AZA, TAC alone was used as maintenance therapy or long-term TAC was used concomitantly with AZA to maintain remission [9]. In our patient, remission was maintained by a long-term administration of TAC alone, which is a rare. Because our patient had an allergic reaction to 5-ASA, it was difficult to use it concomitantly with TAC.

In the treatment of UC, 5-ASA derivatives are usually used for both remission induction and maintenance therapy as first-line drugs and are used concomitantly with a variety of other agents [10]. Consequently, using TAC alone without a 5-ASA derivative is rare. The present case suggests that TAC alone can be used as maintenance therapy. In patients who do not tolerate AZA, TAC can be used for both the induction of remission and maintenance therapy.

A long-term administration of TAC may cause renal damage [11], and thus a careful monitoring of renal function is necessary under such treatment. The development of renal dysfunction requires the discontinuation of TAC and a switch to a biological agent for maintenance therapy.

Conclusion

We treated a rare patient with severe UC in whom remission was induced by TAC and subsequent maintenance therapy was achieved under the control of TAC alone.

References

Select your language of interest to view the total content in your interested language
Post your comment

Share This Article

Relevant Topics

Recommended Conferences

  • Global Experts meeting on Oncology Case Reports
    Aug 29-31, 2017 London, UK
  • Global Experts Meeting on Case Reports
    Osaka, Japan October 09-11, 2017
  • 6th Global Experts Meeting on Medical Case Reports
    October 16-18, 2017 San Francisco, California, USA

Article Usage

  • Total views: 103
  • [From(publication date):
    June-2017 - Jul 28, 2017]
  • Breakdown by view type
  • HTML page views : 82
  • PDF downloads :21
 
 

Post your comment

captcha   Reload  Can't read the image? click here to refresh

Peer Reviewed Journals
 
Make the best use of Scientific Research and information from our 700 + peer reviewed, Open Access Journals
International Conferences 2017-18
 
Meet Inspiring Speakers and Experts at our 3000+ Global Annual Meetings

Contact Us

Agri, Food, Aqua and Veterinary Science Journals

Dr. Krish

agrifoodaquavet@omicsonline.com

1-702-714-7001 Extn: 9040

Clinical and Biochemistry Journals

Datta A

clinical_biochem@omicsonline.com

1-702-714-7001Extn: 9037

Business & Management Journals

Ronald

business@omicsonline.com

1-702-714-7001Extn: 9042

Chemical Engineering and Chemistry Journals

Gabriel Shaw

chemicaleng_chemistry@omicsonline.com

1-702-714-7001 Extn: 9040

Earth & Environmental Sciences

Katie Wilson

environmentalsci@omicsonline.com

1-702-714-7001Extn: 9042

Engineering Journals

James Franklin

engineering@omicsonline.com

1-702-714-7001Extn: 9042

General Science and Health care Journals

Andrea Jason

generalsci_healthcare@omicsonline.com

1-702-714-7001Extn: 9043

Genetics and Molecular Biology Journals

Anna Melissa

genetics_molbio@omicsonline.com

1-702-714-7001 Extn: 9006

Immunology & Microbiology Journals

David Gorantl

immuno_microbio@omicsonline.com

1-702-714-7001Extn: 9014

Informatics Journals

Stephanie Skinner

omics@omicsonline.com

1-702-714-7001Extn: 9039

Material Sciences Journals

Rachle Green

materialsci@omicsonline.com

1-702-714-7001Extn: 9039

Mathematics and Physics Journals

Jim Willison

mathematics_physics@omicsonline.com

1-702-714-7001 Extn: 9042

Medical Journals

Nimmi Anna

medical@omicsonline.com

1-702-714-7001 Extn: 9038

Neuroscience & Psychology Journals

Nathan T

neuro_psychology@omicsonline.com

1-702-714-7001Extn: 9041

Pharmaceutical Sciences Journals

John Behannon

pharma@omicsonline.com

1-702-714-7001Extn: 9007

Social & Political Science Journals

Steve Harry

social_politicalsci@omicsonline.com

1-702-714-7001 Extn: 9042

 
© 2008-2017 OMICS International - Open Access Publisher. Best viewed in Mozilla Firefox | Google Chrome | Above IE 7.0 version