Remicade and antibodies

[Clash]

I have recently seen a couple of posts about members taking solumedrol pre remicade infusion to stave off antibodies. I was under the impression it helped with an allergic reaction but didn't know it prevented antibodies, if so then would an initial combo of 6MP/Imuran or MTX not be necessary?

Here is one of the posts but it isn't the one that first caught my attention on this, I can't pull it up right now but in this one the member is responding to whether Remicade will work after not using it for 4 months(a question posed by the OP)

it has for me. I was off for almost a year. Being so short of time off I thin you should not need anything else. I am also taking soulmedrol to help with the possible build up of antibodies. My IC emails me a few days before my infusion. You might see if your center has that option.

 

[Clash]

I'm doing a bit of quick research, I have found this:

Dr. Siegel:
You are probably correct in stating that he has developed antibodies to the Remicade. An infusion of steroids (like solumedrol) can help in preventing infusion reactions, but this may not be a long term solution. It may be worth considering adding back the Imuran. If he continues to have infusion reactions, or his symptoms start to return, switching to another drug similar to Remicade (such as Humira or Cimzia) may be necessary. These drugs are not yet approved for ulcerative colitis, but in this situation many insurance companies will approve their use

source

 

[my little penguin]

^^^^ yeah that
Was our experience with remicade

Also remember the presence of antibodies increases the likelyhood
Of a reaction.
The abscence of antibodies does not mean a reaction will not occur.
My DS did not have antibodies present but did have more than one reaction to remicade
Even on solumedrol .

 

[Clash]

So, solumedrol sometimes works on the allergic reaction, antibodies or not.
If there are antibodies and solumedrol keeps an allergic reaction at bay but does it also suppress the antibodies and by extention allow for the Remicade to work?
And if there are no antibodies will it prevent antibodies from forming?

 

[my little penguin]

Solumedrol is a steriod
It's does not prevent antibodies from forming.
It does minimize the allergic reaction that occurs sometimes.
It does not prevent an allergic reaction nor does it stop true anaphylactic shock from happening.
DS still reacted while on solumedrol
We were told there was no way to predict how severe the next reaction would be but that they would definitely get worse.
The only proven way to reduce the likelyhood of developing antibodies is the vomit rant use of immunosuppresant such as 6-mp or Mtx.
These however only reduce the odds of antibodies according to some studies but do not eliminate the risk of a of antibodies forming .

They also know some folks have antibodies but still don't react.
I think the science needs to catch up to the meds in this case.

 

[Clash]

Thank you so much for making all that clear, that is what I had in my head but then I thought I might have it mixed up.


MLP rocks!!!:headbang::headbang:

 

[jmckinley]

When Ryan had a reaction he was on methotrexate in addition to the remicade. They wanted to try one more time and gave him solu medrol to try to make the infusion work and also benadryl and slowed the infusion down but he reacted again anyway.

 

[Tesscorm]

A bit dated but an interesting article - discusses remicade and antibodies


Influence of Immunogenicity on the Long-Term Efficacy of Infliximab in Crohn's Disease


http://www.nejm.org/doi/full/10.1056/NEJMoa020888

 

[my little penguin]

Jmckinley-
i thought your son had developed anitbodies so they added mtx
then he had a reaction.

HEre is a good paper on it.

Immunogenicity

Immunogenicity can occur with all biologic agents. The principal reason for originally advocating combination therapy with anti-TNF therapy and an immunosuppressant was to reduce immunogenicity and this practice evolved from experience in rheumatoid arthritis. In CD, it has been demonstrated that concomitant use of an immunosuppressant with biologic therapy may prevent the formation of anti-drug antibodies. In patients undergoing episodic IFX therapy it has been clearly demonstrated that the use of either AZA or MTX is associated with a significant reduction in antibody formation In a study of patients treated concomitantly with IFX plus either AZA or MTX, 48% and 49% exhibited antibodies to IFX, respectively, while 73% of the patients in the group not receiving immunosuppressant therapy demonstrated anti-IFX antibodies . These data support results seen in a previous study which demonstrated that concomitant use of an immunosuppressant in IFX episodic therapy was associated with decreased antibody formation, decreased infusion reactions, and increased sustained responsiveness to IFX Current data suggest that the effect of continuing immunosuppressant therapy on reducing immunogenicity in patients receiving biologic therapy is more pronounced in patients undergoing episodic biologic therapy: a strategy that has been largely abandoned due to lack of efficacy.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3002580/?report=classic

 

[jmckinley]

mlp,

They added the mtx because his blood work wasn't improving after 4 remicade infusions and he ended up in the hospital in June '12. The bloodwork improved after mtx was added, then he had the reactions at infusions 7 and 8 in July and Sept. Turned out the mtx was the only thing working. Bloodwork has been good until now on mtx only. Starting Humira next week :yfrown:

 

[lilikoi]

My son had to go in for his Remicade a full week before schedule
This time we have noticed that mild/moderate symptoms are creeping back only a day after the infusion, whereas it used to be they were held off for at least 4 days before he experienced discomfort again. Does the body start building a resistance this early? This is only his third infusion. We have had to shorten the time in scheduling between infusions because of his worsening symptoms so instead of 0wk, 2wk, 4wk, 8wk we actually did 0wk, 12days, and 3wk.

Thank you all.

 

[my little penguin]

Sometimes it takes the full three infusions plus a couple of days before you see any improvement at all.
So it is good he was /is seeing some.
Depending on how bad he was it just takes time for the remicade to work and build up in his system.


Hopefully it will be smooth sailing for your child form here on out.

 

[crohnsinct]

Ditto what MLP says. My daughter was on Prednisone while loading and early doses so that held her over. Once we tapered Prednisone symptoms returned. THere are lots of tricks the GI's have up their sleeves. Turned out my daughter was just metabolizing the Remi too quickly...it worked just didn't last. So we tightened up the schedule and upped the dosage. She is on every 5 weeks at 10.5/kg now and it works like a charm. I am sure your doc will be pulling antibody and Remi level tests to see where and how to tweak.

Good Luck!

 

[lilikoi]

My son was admitted to the hospital again due to a significant flare. He was on only Remicade 5mg to start and since he was continuing to flare the GI uped the dose to 10mg (third infusion).
Well the day after that increased dose he went into another flare In the hospital the they seem to think he may have developed antibodies to the Remicade and put him on Solumedrol and Protonix via IV. His symptoms settled down and they insisted that the steroid route may be necessary to get the illness under control so it was in with the Prednesone. He is taking oral 40mg daily.
He is doing surprisingly well now at home but we need to discuss him getting off of it as soon as possible. The doctors mentioned the next step would probably be Methotrexate, possibly paired with Humira. I'm afraid that we are treading into a pool of stronger meds with ever increasing side effects...

 

[my little penguin]

My DS reacted to remicade and is now on humira.
I hope the drugs work well for your child.

 

[lilikoi]

Thanks MLP,
I'm kind of nervous because he didn't seem to stay, or rather couldn't stay, on Remicade for that long and now has to be shuttled to Prednesone in such a hurry. The GI didn't give us any directions as to when or how we are going to taper off from 40mg daily. It seems kind of on the high side so I'm anxious to get it to a lower dose but we can't budge until GI says so (we have an appt on the 28th). Been on Prednesone since Sun the 16th.:confused2:

 

[my little penguin]

DS was on 30 mg for a very long time at age 8 and 50 lbs.
Pred really isn't that bad when its needed it will take a while for humira to work so it is a good back up until then .

( we are still waiting for it to work for DS but he was on too low a dose at first and did not do a loading dose since he was doing so well on remicade )

 

[DustyKat]

I have to agree with mlp lilikoi. As much as Pred is a drug that we all have a love/hate relationship with it does have a place in treating acute flares and has saved many a life.

My own son's experience with Pred was not one of the miracle drug that many experience but I can't deny it stabilised his condition when he developed complication after complication. Although he was oral Pred for about 10 weeks it was the IV Hydrocortisone that really served him well.

An average sort of run with Pred for IBD is 2-3 weeks at 40mg and then taper by 5mg every 5-7 days.

Dusty. xxx

 

[lilikoi]

Thanks to you all for helping me calm down My son is doing much better, first time I have seen him pain-free for a full week in months!
I just read an abstract that scared the hell out of me, about Methotrexate and the connection with elemental feeds. I'll post a link here and in the Methotrexate forum too.
http://www.gastrojournal.org/article/0016-5085%2887%2990128-4/abstract
So much to be wary of but I'm getting to a place where I don't agonize as much every time I read or hear about some negative side effect or contraindication. I'm also trying not to hover and question my son a thousand times a day
We are taking things one day at a time and learning to appreciate the little things...

Bless you all

 

[crohnsinct]

lilkoi - Glad your boy is feeling better and doesn't that go a long way to making us feel comfortable about all the drugs.

You have pretty much outlined the progression we have all taken at one time or another. I used to joke that the ped GI's sit in the break room taking bets on how long it is going to take each of us to come around on this or that drug and maybe even challenge their collegues to get us to fold and accept a certain drug. I could see it now, "I give her 3 months" "give me a try, I will break her in a day".

 

[lilikoi]

Ha, ha, ha! Crohnsinct, you are right. I can just see it too.
I was extremely leery of steroid treatments until I got to see the actual results. After my son improved miraculously I rethought my approach to his treatment. In seeking out all the possible harmful side effects of steroids I neglected to look at the BENEFITS of the drug and how those benefits weigh against the negative side effects.
Another consideration is how the drug is metabolized in any one individual's body. Whereas someone could have a terribly hard time with it, another could receive the benefits and be spared the harsh effects. We have yet to see what this is going to do to my boy, he's only been on prednisone for about 14 days now, and the side effects have been minimal but the near elimination of the disease symptoms has been nothing short of astounding. He still suffers from occasional gas and bloating and sometimes gurgling but the debilitating pain is all but gone.
All we can do is continue with his drug treatments as recommended by his GI and keep on keeping on...

Being hopeful and sending out good thoughts

 

[momof8yrold]

MLP, May I know what kind of reaction did your son have with Remicade. My son has reacted during his 3rd, 4th and 6th infusion. His reaction was flushed eyes, cheeks and ears. The reaction happens within the first 5 minutes of his remicade. They stopped the infusion for about 15 mins and started it again. He is good then.
During the 5th infusion, doctor added solumedrol and the infusion went fine. 6th infusion, though he was premedicated with solumedrol..he had facial flushing.
We already know my son has significant anti bodies to remicade. But. .doctor wants to increase the dose to see if it works.
I'm dead scared about infusion and delayed reactions because of antibodies..

 

[Clash]

My son had reactions twice to remicade. The first time flushed chest, face. He felt a little short of breath so infusion stopped solumedrol given infusion started back slower. The second time same thing so after stopping we didn't continue it. His antibodies were tested before second reaction and came back extremely high.

Remicade was stopped altogether because his reactions could be come and more severe.

 

[CrohnsKidMom]

My son has been on Remicade for almost a year now. He was tested for antibodies last fall and didn't have any, thankfully. He has a mild reaction about halfway through his infusion, but it's the opposite-he turns quite pale-but feels hot. No fever though. By the time the infusion is over, he is feeling fine again. He is pretreated with benedryl, as well as Tylenol and a steroid, but he still has this reaction. The nurses keep an eye on it, but say it is not a cause for concern.

 

[malorymug]

When my DS bloodwork showed antibodies, the docs were very careful to make sure that all the premeds (solumedrol, benedryl, tylenol) were on board prior to remicade. Perhaps to prevent a reaction from happening sinces antibodies were getting ready for a fight. Premeds and increasing the remicade dose seemed to work. Latest bloodwork had no antibodies

 

[Mehita]

So, malorymug, your son showed antibodies at one time, but didn't in later testing? My son had that happen and I have yet to find an explanation why antibodies would decrease. Do you have any insight?

DS does Benedryl, Tylenol, and Solumedrol before each infusion because a year ago tests indicated some antibodies. About six months later he was tested again and his antibody level dropped from 24 to 7. Also at that six moth mark, his GI also added methotrexate to further help prevent antibodies. I think DS is where he needs to be medication-wise, but it seems like his GI did a roundabout approach to it.

 

[malorymug]

Yes. Antibodies in January, and no antibodies in May. Docs didn't give me an explanation but we are celebrating. Perhaps having a therapeutic dose constantly in his system prevents the body from fighting against the drug. We had always premedicated and always had MTX on board so the only difference is the amount of remicade both in dose and frequency.