Optimising IBD patient selection for de-escalation of anti-TNF therapy to immunomodulator maintenance

Abstract

ObjectiveInflammatory bowel disease (IBD) is increasingly managed with the use of biologic therapies. National guidelines (National Institute for Health and Care Excellence (NICE)) suggest considering cessation after 1 year of therapy but lack detailed criteria for this. We aimed to describe clinical outcomes from the introduction of a biologic review panel (BRP) to implement modified criteria for cessation of antitumour necrosis factor (anti-TNF) therapy and step down to single-agent immunomodulator.DesignRetrospective review of patient outcomes following BRP implementation.PatientsAll patients on biologic therapy discussed in the BRP within a 5-year period.SettingSingle IBD network covering three hospital sites.InterventionsModified criteria for biologic cessation were based on published evidence; they excluded individuals with no suitable maintenance immunomodulator, previous surgery or evidence of active disease, additional indications for anti-TNF therapy and previous relapse on biologic cessation. All patients with IBD on a biologic were discussed at the BRP.Main outcome measuresRelapse following IBD cessation and relative cost of BRP.Results136 patients with IBD were reviewed, with 45 patients meeting the NICE guideline criteria for cessation. The BRP and modified criteria affected decision to withdraw therapy in 38% of these. Therapy was withdrawn in 27 patients, with a 20% 24-month relapse rate. Younger age at cessation was significantly associated with relapse (p=0.01).ConclusionThe BRP approach has proved a safe and effective means of decision making in stopping biologic therapy. Future work to inform exclusion criteria is required.

Thiopurines Maintenance Therapy in Children With Ulcerative Colitis: A Multicenter Retrospective Study

“…Since thiopurines provide a relatively safe option in children with acceptable remission rates without sacrificing the potential response to anti‐TNF drug, they should be considered either early in the treatment course or as part of a de‐escalation strategy (26,33). Efforts are being made to identify possible clinical features or biomarkers that support de‐escalation of therapy (34).…”

Low-Dose Azathioprine in Combination with Allopurinol: The Past, Present and Future of This Useful Duo

“…However, as the understanding of IBD increases and new treatment targets are identified, the medications being developed are expensive due to high production costs [1][2][3][4]. With health care costs rising globally, many health systems may benefit from optimising older, simpler and cheaper therapies [5][6][7]. Thiopurines, including azathioprine, mercaptopurine and thioguanine, particularly when optimised using therapeutic drug monitoring and/or concomitant allopurinol, are one such class of medications.…”

“…While thiopurines have not been able to demonstrate equivalent effectiveness when compared to biologics, such as anti-tumour necrosis factor (anti-TNF) agents, used alone or in combination with immunomodulators, they do have several advantages [7][8][9][10][11]. The most obvious benefits of thiopurines are reduced cost, ease of administration and simpler storage.…”