Alimentary TractInfliximab as a bridge to remission maintained by antimetabolite therapy in Crohn's disease: A retrospective study
Introduction
The advent of anti-tumour necrosis factor (TNF) agents has established new goals for the management of Crohn's disease (CD). In addition to controlling disease activity, anti-TNF therapy reduces the need for hospitalization and surgery while also improving patient quality of life [1], [2], [3], [4], [5]. However, the economic burden of long-term anti-TNF therapy and the desire of patients to discontinue medication support a strategy of drug withdrawal. If and when a patient should cease infliximab treatment for CD remains a debated issue. A study from the Groupe d’Etude Thérapeutique des Affections Inflammatoires du tube Digestif (GETAID) has evaluated the outcome of patients treated with azathioprine and induction therapy with infliximab [6]. In this study, 113 CD steroid-dependent patients were randomized to receive either infliximab at week 0, 2 and 6, or placebo. The rate of steroid-free remission was significantly higher in the infliximab group than in the placebo group at weeks 12, 24 and 52 (75%, 57% and 38%, respectively) but decreased over time. Patients who had reached steroid-free remission at the end of the study were further evaluated for up to 4 years, and the data demonstrated that infliximab was no longer superior to placebo [7].
Recently, Louis et al. prospectively evaluated the outcome of CD patients using combined therapy after infliximab was discontinued in patients with prolonged remission longer than 6 months [8]. After one year, the rate of relapse was 43.9% (±5.0). An analysis of the clinical and biological markers defined a group with a low risk of relapse. The authors concluded that Crohn's disease patients in stable remission treated with combined therapy consisting of infliximab and an antimetabolite could safely withdraw from infliximab. Re-treatment with infliximab was effective and well tolerated in patients who experienced a relapse. In the absence of any controlled study, further data are warranted.
The aim of this study was to compare the outcome of CD patients in stable remission treated with combined therapy consisting of infliximab and then an antimetabolite after infliximab was discontinued, after induction therapy alone or induction plus at least one year of scheduled maintenance therapy.
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Patients
We retrospectively reviewed consecutive case records of all adult CD patients referred to Henri Mondor university hospital in Paris, France from January 2000 to June 2012. Patients were recruited from our personal database and/or a standardized hospital inpatient dataset. The patients eligible for this study were at least 17 years of age and had received combined infliximab and antimetabolite treatment for active CD. All patients had discontinued infliximab treatment but maintained
Patient characteristics
Ninety-two patients (57 females; median age at inclusion 32.6 [IQR = 23.9–44.4] years) fulfilled the inclusion criteria. Table 1 shows the patient demographic and CD characteristics. All patients were treated with stables doses of antimetabolite therapy for a median duration of 11.0 months (range, 93.6–25.0). Fifty-four patients were included in the induction group, and 38 patients were in the maintenance group. The median follow-up period was 47.1 months (range, 4.4–110.2) for the overall
Discussion
Our study reports the clinical outcomes in 92 patients with CD in stable steroid-free remission on combined therapy after infliximab was discontinued but antimetabolite treatment was maintained. To our knowledge, this is the largest collection of CD patients evaluated at a single centre comparing infliximab withdrawal after induction therapy alone and after at least 1-year scheduled maintenance therapy. In our cohort, the 1- and 2-year treatment-free remission rates were 70% and 52%. There was
Conflict of interest
AA has received payment for lectures from Biocodex and MSD and travel accommodation from Abbvie, MSD and Biocodex. None of the remaining authors have any potential conflicts to disclose about the present study.
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Proposal for an anti-TNF-exit strategy based on trough serum level
2017, BiologicalsCitation Excerpt :The most difficult decision was, to define which further factor might have a predictive value for a relapse-free revival and should be part of the algorithm-criteria. To this regard, the existing data are rare and partially contradictory [20–25]. We consciously chose a small number of criteria, expecting the best empirical value in recent literature.