De-escalating therapy in inflammatory bowel disease: Results from an observational study in clinical practice

Alex Arenas; María José Moreta; Ingrid Ordás; Agnès Fernández-Clotet; Berta Caballol; Marta Gallego; Alejandro Vara; Rebeca Barastegui; Angel Giner; Cristina Prieto; Maria Carme Masamunt; Roberto Candia; Elena Ricart

doi:10.1016/j.gastrohep.2023.07.005

De-escalating therapy in inflammatory bowel disease: Results from an observational study in clinical practice

Gastroenterol Hepatol. 2023 Aug 8:S0210-5705(23)00376-X. doi: 10.1016/j.gastrohep.2023.07.005. Online ahead of print.

[Article in English, Spanish]

Authors

Affiliations

¹ Inflammatory Bowel Disease Unit, Hospital Clínic, Barcelona, Spain; Complejo Asistencial Dr. Sótero del Río, Unidad de Gastroenterología, Santiago, Chile; Facultad de Medicina Clínica Alemana-Universidad del Desarrollo, Gastroenterología, Santiago, Chile.
² Gastroenterology Department, Hospital Clínic, Barcelona, Spain.
³ Inflammatory Bowel Disease Unit, Hospital Clínic, Barcelona, Spain; Gastroenterology Department, Hospital Clínic, Barcelona, Spain; Institut d'Investigacions Biomèdiques Pi i Sunyer (IDIBAPS), Centro de Investigación Médica en Red (CIBER-EHD), Chile.
⁴ Inflammatory Bowel Disease Unit, Hospital Clínic, Barcelona, Spain; Gastroenterology Department, Hospital Clínic, Barcelona, Spain.
⁵ Departamento de Gastroenterología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile.
⁶ Inflammatory Bowel Disease Unit, Hospital Clínic, Barcelona, Spain; Gastroenterology Department, Hospital Clínic, Barcelona, Spain; Institut d'Investigacions Biomèdiques Pi i Sunyer (IDIBAPS), Centro de Investigación Médica en Red (CIBER-EHD), Chile. Electronic address: ericart@clinic.cat.

PMID: 37562767
DOI: 10.1016/j.gastrohep.2023.07.005

Abstract

Background and objectives: Combination therapy with an immunomodulator (IMM) and an anti-TNF is commonly recommended in Crohn's disease (CD) and ulcerative colitis (UC) patients. However, little is known about relapse rates after therapeutic de-escalation. This study aimed to evaluate the risk of relapse in a cohort of UC and CD patients with long-standing clinical remission after discontinuation of IMM or anti-TNF and to identify predictive factors for relapse.

Methods: This retrospective study included patients with UC or CD on combination therapy and clinical remission for at least 6 months. IMM or anti-TNF was stopped upon physician decision. Primary objective was to evaluate the relapse rates after discontinuation of IMM or anti-TNF and to analyze predictors of relapse.

Results: The study included 88 patients, 48 patients (54.5%) discontinued IMM and 40 (45.5%) anti-TNF. During follow-up, relapse rates were 16.7% and 52.5% in the IMM discontinuation group and anti-TNF discontinuation group, respectively (p<0.001). Multivariate analysis showed that anti-TNF discontinuation (HR=3.01; 95% CI=1.22-7.43) and ileal CD location (HR=2.36; 95% CI=1.02-5.47) were predictive factors for relapse while inflammatory CD phenotype was a protective factor (HR=0.32; 95% CI=0.11-0.90). Reintroduction of anti-TNF upon relapse was effective and safe.

Conclusion: Anti-TNF discontinuation led to significantly higher relapse rates compared to IMM discontinuation in UC and CD patients on combination therapy. Anti-TNF discontinuation and ileal CD location were identified as predictive factors for relapse while inflammatory CD phenotype was a protective factor. Retreatment after anti-TNF discontinuation was effective and safe.

Keywords: Anti-TNF; Colitis ulcerosa; Crohn's disease; Discontinuación; Discontinuation; Enfermedad de Crohn; Enfermedad inflamatoria intestinal; Immunomodulators; Inflammatory bowel disease; Inmunomoduladores; Ulcerative colitis.