Combination Therapy with Intensive Granulocyte and Monocyte Adsorptive Apheresis plus Adalimumab: Therapeutic Outcomes in 5 Cases with Refractory Crohn's Disease

Adalimumab (ADA) is applied to induce remission in patients with Crohn's disease (CD) naïve to chimeric anti-tumor necrosis factor-α (anti-TNF-α), infliximab or patients with loss of response to scheduled maintenance infliximab. Adsorptive granulocyte and monocyte apheresis (GMA) depletes elevated/activated myeloid lineage leucocytes as sources of inflammatory cytokines and has been used to treat patients with CD. This study was to investigate the efficacy of intensive GMA in combination with ADA as remission induction therapy in cases of CD refractory to medications including anti-TNF-α therapies. Between December 2010 and February 2012, 5 consecutive cases with refractory CD were treated with intensive GMA (2 sessions per week) plus ADA to induce remission. CD activity index (CDAI), C-reactive protein (CRP), and endoscopic findings based on the simple endoscopic score for CD (SES-CD) at baseline and 10 weeks post 5 ADA injections were applied to determine treatment efficacy outcomes. At week 10 post ADA treatment, clinical remission together with normal CRP levels were achieved in all 5 cases, while SES-CD scores reflected marked improvement in 3 cases and partial improvement in 2 cases who had extensive deep longitudinal CD lesions. The CDAI and CRP values at baseline were 324 ± 118 and 4.9 ± 3.3 mg/dl, respectively. The corresponding values after treatment were 100 ± 28 (p = 0.024) and 0.2 ± 0.2 mg/dl (p = 0.038). In these 5 cases with medication-refractory CD, combination therapy with intensive GMA followed by 5 ADA shots appeared to be an effective and safe intervention for inducing clinical remission.