Intravenous trough level guided dose intensification of ustekinumab for refractory severe pyoderma gangrenosum – a literature review

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Introduction Pyoderma gangrenosum (PG) is a neutrophilic dermatosis, which can occur as an extraintestinal manifestation in inflammatory bowel disease (IBD). Regarding treatment, evidence exists for ustekinumab (UST) [ 1 ]. However, management of PG occurrence during UST treatment is not clear. We report of a 30-year-old woman with Crohn’s disease (CD), who developed severe PG on the right leg. She was receiving subcutaneous (s.c.) UST at 90 mg every 4 weeks for CD maintenance therapy but had a decline in serum trough concentration before PG onset. Our aim to investigate was whether a trough level guided dose intensification via intravenous re-induction would be effective in PG treatment. Methods We searched in PubMed for data regarding PG treatment with UST using the terms “ustekinumab and pyoderma gangrenosum”, “ustekinumab trough levels” and “ustekinumab intravenous re-induction”. We administered 130 mg UST intravenously 4 weeks after the last s.c. injection, followed by two more infusions 4 and 8 weeks afterwards. Serum trough levels were measured before each infusion. Results Our literature review included evidence for successful PG treatment with UST in 9 IBD patients achieving complete remission in 8 cases [ 1 ]. We did not find any data regarding UST trough level measurements in PG treatment. In our patient serum UST trough concentration before PG onset was 1.93 µg/ml. During re-induction it increased to 8.35 µg/ml 4 weeks after the first infusion and was 7.28 µg/ml after 8 weeks. PG showed a complete remission 20 weeks after onset. Conclusion Intravenous UST dose intensification could be an option for severe cases of pyoderma gangrenosum although further studies correlating ustekinumab trough levels with clinical response are needed. Publication History Article published online: 24 May 2023 © 2023. Thieme. All rights reserved. Georg Thieme Verlag Rüdigerstraße 14, 70469 Stuttgart, Germany

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