Pediatric Rheumatology Online Journal → June 2003 → Medical Treatment → Anti-tumor necrosis factor therapy→ Abstract #56
                                                                August 2003 → Newer Treatments → Anti-Tumor Necrosis Factor Therapy → Abstract #56

NIACIN-LIKE EFFECT ASSOCIATED WITH INFLIXIMAB THERAPY IN SYSTEMIC JRA

G. McIlvain-Simpson, M. L. Becker, C. D. Rose

¹Pediatrics, duPont Childrens Hospital, Thomas Jefferson University, Wilmington, DE, United States

Infliximab is approved by the US FDA for Crohn's and RA. Although clinical trials have identified serious adverse effects to be infection, hypersensitivity and infusion reactions, consensus is that the drug is safe. Clinical trials for JRA are currently underway, and the drug is effective in Ankylosing Spondylitis, Psoriasis, and Sarcoidosis. We and others, have been using off-label Infliximab for refractory pediatric rheumatic diseases. We identified two children with an initially drastic, yet ultimately benign niacin-like effect, which has been poorly recognized in pediatrics.
Case 1: A 3 year-old Caucasian male with sJRA and history of MAS had persistent disease activity despite MTX and steroids. At his 4^thInfliximab infusion, he developed facial flushing and cough (O2 sat 97%) which resolved after the infusion was discontinued. At his 5^th dose, he was premedicated 2 days with Prednisolone (1mg/kg), along with IV Decadron (2mg IVPB) 1 hour prior to infusion. One hour into infusion, he developed facial flushing and cough. The drug was stopped, with no effects upon re-challenge. Prior to his 6^th dose, the patient was premedicated with ASA (325mg), and had no observable adverse effects.
Case 2: A 19 year-old Hispanic male with sJRA, was steroid dependent and intolerant to Etanercept. Facial flushing and chest tightness without wheeze developed during his 5^th Infliximab infusion (O2 sat 92%). He received diphenhydramine IV and albuterol. He was rechallenged without reaction until his 10^th infusion when he again developed facial flushing and chest tightness. His next infusion will include premedication with ASA 325mg.
We describe a previously under-recognized Infliximab side effect in pediatrics; a severe niacin-like reaction. It is probably not unlike the niacin-like PGD2 effects well described in the literature, with facial flushing and systemic effects secondary to vascular dilatation. Modification of Infliximab protocol, to include ASA 325mg, was effective in one patient. Further experience with this protocol change will be described.