Anti-TNF and Crohns Disease: When Should We Stop?

Abstract

When to stop anti-TNF therapy in Crohn's disease (CD)? This is a very important question both for patients and physicians. There is no published evidence to clearly and definitely answer this question. However data on natural history of CD, long term safety of biologies, outcome after immunosuppressors (IS) cessation and some preliminary studies on biologies cessation may help us to discuss this topic. One could argue that there is currently no good reason to stop anti-TNF therapy in a patient who is in stable remission and can tolerate this drug very well. The decision to stop an anti-TNF treatment is thus currently based on a compromise between the benefits/risks and cost of such long term treatment. While it appears now clearly that prolonged anti-TNF therapy is associated with favourable outcome with sustained remission, reduced surgeries and hospitalisation as well as absence of significant increase in mortality or cancers, the cost-effectiveness which is probably favourable for short and mid-term treatment (up to one year), may be less optimal for very long term treatment. In this perspective however, prospective studies should be performed to adequately assess long term evolution, disease outcome, safety and global cost of strategies based on treatment reduction with IS maintenance alone or even full treatment cessation.

Systematic review: factors associated with relapse of inflammatory bowel disease after discontinuation of anti‐TNF therapy

“…It remains unknown when, and if, anti‐TNF agents can ever be stopped. In most countries, the decision to discontinue anti‐TNF drugs is made on an individual basis by weighing up benefits against risks and cost‐effectiveness . Cost of therapy is becoming a major issue in the decision on whether or not to prescribe biological drugs, and it is important to identify patients who will remain in long‐term remission after discontinuation of anti‐TNF therapy.…”

Low Discontinuation Rate of Infliximab Treatment in Steroid-Dependent/Refractory Crohn’s Disease Patients

“…To date, there are no established guidelines on whether and when IFX can be interrupted safely in IBD patients with long-standing remission [1,3,20,21].…”

Use of biological molecules in the treatment of inflammatory bowel disease

“…This question has not yet been explored in prospective clinical trials. If induction therapy fails to achieve a response or if serious and/or allergic reactions occur, the anti‐TNF‐α agent should be stopped [115]. Relapse during continued maintenance therapy should trigger clinical reassessment and in some cases include assays for anti‐TNF‐α antibodies and levels of the active substance.…”

“…This question has not yet been explored in prospective clinical trials. If induction therapy fails to achieve a response or if serious and ⁄ or allergic reactions occur, the anti-TNF-a agent should be stopped [115].…”