This review article (Inflamm Bowel Dis 2014; 20: 757-66) examines the question of whether and when anti-tumor necrosis factor (anti-TNF) agents can be stopped in Crohn’s disease (CD) patients in remission. This topic is particularly helpful since this comes up frequently in clinical practice.
As recently as a few years ago, one expert advised me that starting an anti-TNF agent (like infliximab or adalimumab) was like getting married. Once you committed, you stayed in that relationship indefinitely. Of course, it is well-known that individuals get divorced. In medical terms, I guess that would be the equivalent of developing antibodies to the anti-TNF agent or other adverse reactions. Switching from one anti-TNF to another would be equivalent to marital infidelity.
So what does this review article say about all of this? The article examines nine studies with a little more than 500 patients. “Current evidence suggests that a group of CD patients, possibly 30% to 40% in clinical remission while on IM (immunomodulators) and infliximab can stop the latter and maintain clinical remission for a relatively long interval. It seems that, if followed long enough, virtually all patients (including those on IM) will eventually develop clinical recurrence.”
If tempted to separate but not divorce anti-TNF therapy, the authors recommend, in addition to clinical remission, “normal colonoscopy (and/or normal surrogate markers of disease activity) should be adopted as a criterion when stopping therapy and during follow-up….As of today, many authors do not recommend to routinely stop anti-TNF agents in patients responding to this therapy and in the absence of other issues. Others propose to stop them after a minimum of 2 years of clinical and endoscopic remission or longer if only clinical remission can be documented…
If costs or other issues are present, we suggest to cautiously stop anti-TNF agents only in patients on combination therapy with profound (clinical, biochemical, and endoscopic) and long lasting (>1 year) remission and continuing the IM. Such patients should be closely followed by serial determinations of fecal calprotectin and inflammatory indices, and the medication immediately restarted in the presence of a flare. When in doubt, colonoscopy should be performed.”
Take-home message: Most patients are better off staying married to their anti-TNF therapy.
Also noted: Inflamm Bowel Dis 2014; 20: 742-56. Clinical Utility of Fecal Biomarkers for the Diagnosis and Management of Inflammatory Bowel Disease. This is a useful review with 103 references.