Remicade (aka Mighty Mouse Juice) Day

or "My first dose of Remicade"

Today was the day and it was a long time coming.  I was first approved to begin treatment with Remicade back in June of 2014, so it has been more than eight months from approval to my first infusion.

What is Remicade

Remicade is one of the class of most powerful drugs used to treat Crohn's Disease.  These drugs are called "biologicals" or "biologics":

"biological, is any medicinal product manufactured in or extracted from biological sources. Biopharmaceuticals are distinct from chemically synthesized pharmaceutical products."
Biopharmaceutical, Wikipedia

and more specifically:

"However, in most cases, the term "biologics" is used more restrictively for a class of therapeutics (either approved or in development) that are produced by means of biological processes involving recombinant DNA technology.
...
Monoclonal antibodies. These are similar to the antibodies that the human immune system uses to fight off bacteria and viruses, but they are "custom-designed" (using hybridoma technology or other methods) and can therefore be made specifically to counteract or block any given substance in the body, or to target any specific cell type..."
Recombinant DNA, Wikipedia

In these texts the follow terms mean the same thing:

• anti-TNF
• TNF antagonist
• TNF inhibitor

Another interesting bit, is that there is more than one type of TNF cytokines.  The one specifically identified as the cause of Crohn's Disease is TNF-α.  I vaguely recall that TNF-β is involved in Ulcerative Colitis.

What does that all mean?

Remicade was developed in mice by combining human and mouse DNA to form antibodies to tumor necrosis factor (TNF).  The antibody protein formed is a chimeric antibody - part mouse protein/part human protein.

TNF is part of the metabolic pathway that is the damage mechanism in Crohn's Disease (CD). Diseases like Ulcerative Colitis (UC) and Rheumatoid Arthritis (RA) use the same metabolic cascade up to a point and then diverge. This is why Remicade is sometimes less effective in other diseases.

Remicade was biologically engineered to shutdown the CD damage mechanism. However, they discovered it also helped with a number of other autoimmune diseases like RA & UC.

Similarly, Humira was biologically engineered to shutdown the RA damage mechanism but was shown to be effective in other diseases like CD & UC.

"Mighty Mouse Juice?"

Because the drug was first developed in mice and the antibody includes part of a mouse protein, people taking it often affectionately call Remicade "mouse juice".  Some people add on "Mighty" because the drug stops the body's attack on itself and allows the patients to feel much better - with much better = Mighty.

Reactions

Infusion Common
Remicade infusions often cause a number of negative side effects.  Perhaps the most common but not dangerous of these are:

1. Fatigue
2. Headache
3. Joint Aches

Infusion Dangerous
Because part of the antibody is a mouse protein, it's possible that the patient will suffer a severe reaction that requires immediate medical attention.  The drug is administered in a specialized infusion center with a doctor and drugs to treat these emergency medical conditions.  Uncommon or rare reactions during infusion that may require treatment are:

1. Anaphylaxis (allergic reaction)
2. Tachycardia (rapid heart rate)
3. Blood pressure drop
4. Blood pressure spike

Increased Vulnerability
Remicade works by shutting off a key component of the human immune system.  This makes patients more vulnerable to certain disease - especially cancer and certain infections.  I already have one of these infections - fungal pneumonia.  However, I'm being treated for it and I seem to be rapidly overcoming the disease.  While taking this drug (which I may have to take for the rest of my life), I'll be more vulnerable to:

1. Fungal pneumonia
2. Tuberculosis
3. Cancer

My infusion

My doctor prescribed no premedications (aka "pre-meds").  These are medications that can reduce the negative side-effects of the Remicade infusion.  However, my doctor recommended that on my own I take a couple of Tylenol before going to the infusion center.

While at the infusion center they pushed a small IV bag of saline solution to improve my hydration Good hydration levels seem to help stave off negative side-effects.  My wife took this picture right after finishing this bag but right before we started the infusion.

Preparing for Remicade infusion

The infusion took about two hours.  I took this "selfie" right at the end of the infusion.  I don't know if you can tell but I got very drowsy right at the end of the infusion.

My Remicade "selfie"

Because I am doing my loading doses (I'll do another post on that), they wanted to ensure I could tolerate the drug.  They used the following dosing schedule to infuse 400 mg over 120 minutes:

1. 3 mg/15 min
2. 14 mg/15 min
3. 46 mg/30 min
4. 112 mg/30 min
5. 225 mg/30 min

The maximum rate of infusion is equal to about three times the rate of infusion they expect to use during a normal infusion.  This made me think of something called proof testing of cannons, in which a cannon is fired with 2-3 times its normal charge to ensure it can be used safely.

The rapid rate of infusion at the end proves that I can tolerate the medication and am unlikely to experience bad side-effects.