Remicade is a brand-new drug used in the treatment of Crohn’s disease. It consists of antibodies that block the substance called TNF (tumour necrosis factor). This TNF protein is found in the blood of patients with Crohn’s disease and is thought to be the most important factor doing damage to the wall of the bowel in Crohn’s. Excessive production of TNF runs parallel with a rise in the activity of the disease.

Remicade is a drug made solely to block TNF; 75% of this substance is produced in humans and 25% in mice. It was approved by the FDA in May 1998. It has recently been approved for use in rheumatoid arthritis as well.

Who should have Remicade?

Patients with Crohn’s disease who get no benefit from the classical drugs should use this drug (Salazopyrin, Salofalk, prednisolone, Imuran). It is also given in Crohn’s disease running its course with a fistula, and in difficult cases of ulcerative colitis. A fistula means a channel joining two organs to each other; fistulas can develop, for instance, between the bladder and the bowel, the bowel and the skin, or one part of the bowel and another.

How is Remicade given?

It is given into a vein, as an intravenous infusion. It should be given in the doctor’s rooms or in hospital, under the observation of a nurse. Giving the infusion takes two hours.

In patients with moderate and severe Crohn’s without a fistula a single infusion may be given; in those with a fistula and severe disease three infusions (one each at weeks 0, 2 and 6) may be given, and in these patients treatment may be continued with an infusion every eight weeks until they improve.

Because this drug is new, knowledge about its rates of success in treatment is steadily growing. The rates of success in short-term treatment appear quite high (above 80%). In patients with a fistula, half the fistulas close within the first few treatments. There is at present no knowledge of which patients it will succeed in.

What if there is a stricture?

A stricture is a narrowing caused by fibrous tissue developing in the bowel; if this has developed, patients with Crohn’s disease frequently go into a state of partial obstruction of the bowel called ileus. These patients are unable to pass wind or stool, and have nausea and vomiting. Remicade will probably not benefit this group of patients with Crohn’s. This group of patients needs surgical treatment.

Side effects

An infusion of Remicade is generally well tolerated. Five per cent of patients have complaints of weakness, dizziness, nausea and itching, which pass off of their own accord. In 2% of patients the drug has to be stopped. The side effects are generally eased with paracetamol or Benadryl.

In fewer than 1% of patients, signs resembling lupus develop (fever, pleurisy, flitting joint pains). These complaints ease on stopping the drug and giving a steroid.

Very uncommonly, infections can develop in patients because of the disturbance to immunity (of the airways, of the urinary tract and so on).

Does Remicade cause cancer?

In the short term, no. Long-term studies are continuing.

What does it cost?

It is quite an expensive drug. In the USA each infusion costs about 2,500 dollars.