A recent study provides information about elective switching from infliximab (IFX) to adalimumab (ADA) in stable Crohn’s disease (CD) (Inflamm Bowel Dis 2013; 19: 761-66). As a practical matter, patients and families inquire about switching therapy due to potential convenience and flexibility. Thus far, there is little data to guide clinicians. As such, the authors explored this question by designing an open-label study which would allow enrollment of any patients who had stable disease for >6 months (Harvey-Bradshaw Index ≤ 8) on IFX therapy.
In total, 29 patients with CD were enrolled with an average age of 39. Twelve had previous resections.
Key results:
- 21 patients (72%) were able to remain on ADA at 54 weeks. 8 patients discontinued ADA due to disease activity (n=3), side effects (n=4), or other symptoms (n=1).
- 4 patients were restarted on IFX therapy; 1 required dose intensification.
- At 54 weeks, 13 patients indicated a preference for IFX due to efficacy (n=9) or safety profile (n=4). 12 patients indicated a preference for ADA. 4 patients had no preference.
The authors state that a recommendation to avoid elective switching. In their study, 28% were not able to be maintained on ADA therapy, more patients preferred IFX after experiencing both therapies, and switching back to IFX has been associated (in some) with reduced efficacy. The main concern with an elective switch is the potential loss of response with very limited therapeutic alternatives.
The authors note that their study showed better results with an elective change than a previous study (the SWITCH trial, n=73). In the SWITCH trial, “elective switch from IFX to ADA in patients with stable CD led to 47% of patients requiring dose intensification or interruption of treatment” in the ADA arm compared with 16% of patients who continued IFX therapy. (Adalimumab in Crohn’s Disease Controlled by Infliximab)
The better outcomes in the current trial may have been due to selection of patients with milder disease and the more frequent use of concomitant immunosuppression. In the current trial, 52% had concomitant immunosuppression (48% thiopurine, 4% methotrexate); in contrast, only 17% received concomitant immunosuppression in the SWITCH trial. Another important difference was that the patients in the current trial received 160-80 loading doses rather than 80-40 induction. Also, the trial designs were different. The current trial enrolled patients without randomization; in contrast, the SWITCH trial randomized some patients to continue IFX and others to change to ADA therapy.
Related reference:
- -Gut 2012; 61: 229-34. SWITCH trial.
Related blog references:
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