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When and how to de-escalate therapy in inflammatory bowel diseases

The latest Alimentary Pharmacology & Therapeutics evaluates studies that de-escalate therapy in IBD.

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Therapeutic objectives are currently evolving in inflammatory bowel diseases (IBD) from control of symptoms towards improvement of long-term disease outcomes.

In patients achieving remission, safety concerns – infections or neoplasia – and economic issues are prompting de-escalation strategies.

Drs Pariente and Laharie from France provide an overview of studies on de-escalating therapy in IBD.

The team performed a structured search in Pubmed, the Cochrane Library and EMBASE was performed using defined key words, including full text articles and abstracts in English language.

The research team identified 11 studies, investigating cessation of immunosuppressants (IS) and/or anti-TNF treatments.

In patients receiving immunosuppressants alone, relapse rate at 12 months after cessation is 20% in Crohn's
Alimentary Pharmacology & Therapeutics

Patients exposed to a combination of IS and anti-TNF have an increased risk for infections, especially due to opportunistic agent, without any clear signal for associated cancers when compared to those receiving single therapy.

In patients receiving IS alone, relapse rate at 12 months following IS cessation is close to 20% and 30% in Crohn's disease (CD) and ulcerative colitis (UC) respectively.

The team found no study specifically evaluating anti-TNF treatment withdrawal in case of scheduled anti-TNF monotherapy in IBD.

In patients receiving combination therapy with IS and infliximab (IFX) for at least 6 months, relapse rate of IFX failure following IS cessation is near to 20% at 24 months, and seems to be similar in patients who maintained combination therapy.

The researchers noted that in case of anti-TNF therapy, cessation in CD patients in combo-therapy proportion of relapse is high, close to 40% and 50% over 1 year and 2 years respectively.

Regarding higher risk of adverse events, some special situations – young males, pregnancy and elderly – should be managed specifically and de-escalating treatment considered.

Dr Laharie and colleague conclude, "De-escalating treatment strategy should be mainly considered in patients with high risk of severe adverse events and low relapse risk (patients in deep remission) after drug withdrawal."

"For these reasons, cessation of anti-TNF treatment and/or immunosuppressants should be a case by case decision in highly selected patients."

Aliment Pharmacol Ther 2014: 40(4): 338–353
25 July 2014

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