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• Intravenous pulse cyclophosphamide therapy in Crohn's disease and ulcerative colitis
  Zsolt Barta
  Published on: 18 April 2016

• Published on: 18 April 2016

  Intravenous pulse cyclophosphamide therapy in Crohn's disease and ulcerative colitis

  • Zsolt Barta, Gastroenterologist
  • Other Contributors:
    • Laszlo Toth, Gabor G. Szabo, Gyula Szegedi and Margit Zeher

  Dear Editor

  The management of refractory, severe inflammatory bowel disease (IBD) is yet an unsolved problem. We read with interest the article by Stallmach and colleagues reporting safety and efficacy of intravenous pulse cyclophosphamide in acute steroid refractory IBD.[1]

  In common with other disease, the aims of therapy in IBD fall into three categories:

  (i) induction of remission;...

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  Dear Editor

  The management of refractory, severe inflammatory bowel disease (IBD) is yet an unsolved problem. We read with interest the article by Stallmach and colleagues reporting safety and efficacy of intravenous pulse cyclophosphamide in acute steroid refractory IBD.[1]

  In common with other disease, the aims of therapy in IBD fall into three categories:

  (i) induction of remission;
  (ii) maintenance of remission; and
  (iii) prevention of relapse, all of which should be undertaken with minimal mortality and morbidity either from the disease itself or the therapy.

  Based on the previous observations of improvement in autoimmune diseases (i.e. vasculitides) Cyclophosphamide can be the primary cytotoxic drug: pulse intravenous cyclophosphamide is probably equally effective as oral cyclophosphamide at inducing remission and this remission is usually maintained by continuing cyclophosphamide for 3–6 months before changing to a combination of other per os therapy. Therapy must be continued to prevent relapse and for maintenance.[2]

  We would like to report some other cases to enrich the experiences. In our cohort we included patients with Crohn’s disease (CD) and ulcerative colitis (UC). Four patients with CD and four with UC: all were diagnosed according to the standard criteria. They did not respond to conventional therapy so we treated them with pulse cyclophosphamide therapy monthly (for 6 months, 800mg each time). Most patients entered into remission after the second/third cyclophosphamide pulse. Disease activity decreased, there was no side effects, no toxicity, and all the patients went into long lasting remission. For the maintenance, patients with CD were treated with methotrexate (10mg/week) and patients with UC were treated with azathioprine (100mg/day). Remission seems to be stable.

  These findings suggest that aggressive immunosuppressive therapy may be useful in some refractory patients and further controlled study should be considered in order to full evaluate this type of treatment as a potential therapy in IBD.

  IBD continue to pose a challenge to clinicians. Over the past few years there have been significant advances in our understanding of pathogenesis and treatment. These advances will hopefully in the next few years lead to more specific and targeted treatments, with consequent improvements in clinical outcomes. Intravenous pulse cyclophosphamide may be a safe and effective treatment in patients with severe IBD unresponsive to "conventional" treatment. It is also recommended as a first-line adjunct to or replacement of systemic corticosteroids in the treatment of IBD.

  References

  (1) Stallmach A, Wittig BM, Moser C et al. Safety and efficacy of intravenous pulse cyclophosphamide in acute steroid refractory inflammatory bowel disease. Gut 2003;52(3):377-82.

  (2) Watts RA, Scott DG, Pusey CD et al. Vasculitis-aims of therapy. An overview. Rheumatology (Oxford) 2000;39(3):229-32.

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  Conflict of Interest:
  None declared.

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