Successful Use of Infliximab in the Treatment of Corticosteroid Dependent Collagenous Colitis (2012)

A 58-year-old woman status-post Roux-en-Y gastric bypass for obesity experienced two months of diarrhea with up to 12-15 watery bowel movements daily along with night time symptoms and fecal incontinence. After stool cultures, ova and parasite examination, and C. difficile toxin PCR were unrevealing for infection, the patient underwent colonoscopy and was diagnosed with collagenous colitis based on an endoscopically normal appearing colon and classic histology on random biopsies. The patient had been taking ibuprofen and a dexlansoprazole and both were discontinued. The patient was initially treated with budesonide 9 mg daily. The patient had no response and was given adjunctive therapies including diphenoxylate/atropine, loperamide, and bismuth with no response. She was given mesalamine but this was held due to nausea and vomiting. The patient also failed a trial of cholestyramine for one month. The patient had then had 6 months of diarrhea and experienced a 10-lb weight loss and was then hospitalized for dehydration and given IV Solu-Medrol. Stool culture grew Aeromonas hydrophilia caviae and this was treated to eradication with trimethoprim-sulfamethoxazole. The patient had persistent symptoms and was discharged on 6-mercaptopurine 50 mg daily, octreotide 50 mcg subcutaneous injection twice daily, and prednisone. Four weeks later, the patient was hospitalized for acute pancreatitis thought to be due to the 6-mercaptopurine; this was discontinued. Other unsuccessful treatment attempts included alosetron 1 mg twice daily, tincture of opium, and Boswellia serrata extract. She then came to our medical center where she underwent esophagogastrojejunoscopy with jejunal biopsies were negative for celiac disease. A neuroendocrine tumor work up was negative including calcitonin, VIP, and 24 hour HIAA. Magnetic resonance enterography was normal. Colonoscopy was repeated, again confirming the diagnosis of collagenous colitis. After 18 months of symptoms the patient was considered for colectomy with reversal of her Roux-en-Y gastric bypass, but salvage therapy was attempted with infliximab with induction dosing (5 mg/kg intravenously at weeks 0, 2, and 6) with oral methotrexate 12.5 mg/week. A mild transaminase elevation was successfully managed with a dose reduction to 7.5 mg of weekly oral methotrexate. The patient began to notice some improvement in her symptoms and was able to begin tapering her prednisone at week 4 of infliximab treatment. Repeat colon biopsies at week 5 of infliximab therapy revealed persistent collagenous colitis. The patient was off prednisone and without diarrhea at 8 weeks and gradually returned to her baseline weight. At approximately 6 months following infliximab initiation, the patient remained asymptomatic and off corticosteroids. Repeat colon biopsies revealed a normal appearing colon with no evidence of collagenous colitis. Relapse and steroid dependence is not uncommon in microscopic colitis. Anti TNF use has been reported as successful in 5/7 patients with refractory microscopic colitis. We demonstrate the successful use of infliximab in a patient with severe refractory collagenous colitis resulting in symptomatic and histologic remission. Anti-TNF therapies should be considered in patients with refractory or corticosteroid dependent collagenous colitis.