Infliximab offers hope in refractory sarcoidosis

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Infliximab offers hope in refractory sarcoidosis



October 25, 2005



Janis



Chicago, IL - Evidence continues to accumulate suggesting that TNF

inhibitors may be useful in some cases of sarcoidosis that do not

respond to other treatment [1]. In the October 15, 2005 issue of

Arthritis Care & Research,Dr Nadera J Sweiss (University of Chicago,

IL) and colleagues report nine such patients treated successfully

with infliximab (Remicade, Centocor).

" We have previously used infliximab in the treatment of refractory

sarcoidosis and have found that the drug was effective and safe. In

this report, we describe nine patients with refractory sarcoidosis

who were treated consecutively and experienced an excellent clinical

response to infliximab, " Sweiss writes.

Infliximab quickly reduces sarcoidosis symptoms

Sweiss et al conducted a retrospective chart review of patients with

refractory sarcoidosis treated with infliximab between January 2001

and October 2004. All had prior treatment with oral corticosteroids

and/or steroid-sparing agents with little effect. Six had taken

methotrexate without significant response.

Three patients had refractory sarcoidosis of the upper respiratory

tract. Three others had disfiguring skin involvement. One patient had

significant lymphadenopathy mimicking lymphoma. One had splenomegaly

and profound fatigue. The final patient had necrotizing sarcoid

conjunctivitis that had not improved after multiple eye surgeries and

was causing progressive bilateral loss of vision.

Patients were treated with infliximab at doses of 3 to 5 mg/kg at

weeks 0, 2, and 6 and then every six to eight weeks. This produced

remarkably rapid improvement in all nine patients, beginning in some

as early the second week.



" We were surprised by the rapidity of relief of symptoms, especially

in patients with skin sarcoidosis and sarcoidosis of the upper

respiratory tract. "



" We were surprised by the rapidity of relief of symptoms, especially

in patients with skin sarcoidosis and sarcoidosis of the upper

respiratory tract, " Sweiss tells rheumawire. " This raises the

question of what is the best time to start treatment for lung

sarcoid. Maybe if we started early on before fibrosis starts we would

have a better chance of preserving lung function. Other questions

concern long-term safety and optimal duration of therapy. . . . I do

believe that anti-TNF therapy in combination with other

immunosuppressive medications might prove useful for a subset of

patients with refractory sarcoidosis. "

One of the six patients taking concomitant prednisone was able to

stop prednisone after beginning infliximab, and four of six were able

to reduce dosages from 20 to 80 mg/day to 5 to 10 mg/day. All five

patients taking concomitant methotrexate were able to reduce the

dosage from 20 mg/week to 5 to 10 mg/week.

The authors write, " All patients had significant improvement in the

index organ involvement and experienced no recurrence of symptoms

during the follow-up period between four and 42 months. "

One patient discontinued infliximab following development of drug-

induced lupus, which resolved after drug discontinuation. The other

eight patients had no major adverse events. Sweiss notes that

patients with refractory sarcoidosis are likely to require multiple

sequential infusions of infliximab to maintain disease control.

Sweiss says that a good candidate for infliximab would be the patient

with pulmonary and extrapulmonary sarcoidosis who has failed one or

two immunosuppressive medications. She notes that there is currently

no standard of care and no FDA-approved therapy for sarcoidosis.

Patients who have serious ongoing infections, solid tumors, lymphoma,

or a history of tuberculosis would not be candidates for infliximab.

Sweiss NJ, Welsch MJ, Curran JJ, Ellman MH. Tumor necrosis factor

inhibition as a novel treatment for refractory sarcoidosis. Arthritis

Rheum 2005; 53:788-791. 16208666