Tailoring Biologic or Immunomodulator Treatment Withdrawal in Inflammatory Bowel Disease

Abstract

There is currently no cure for inflammatory bowel disease. Most recent treatments and treatment strategies allow for healing intestinal lesions and maintaining steroid-free remission in a subset of patients. These patients and their doctors often ask themselves whether the treatment could be withdrawn. Several studies in both Crohn's disease and ulcerative colitis have demonstrated a risk of relapse, which varies between 20 and 50% at 1 year and between 50 and 80% beyond 5 years. These numbers clearly highlight that stopping therapy should not be a systematically proposed strategy in those remitting patients. Nevertheless, they also indicate that a minority of patients may not relapse over mid-term and that those who have relapsed may have benefited from a drug-free period before being treated again for a new cycle of treatment. In this context, it would be good to optimally select patients who can be candidates for a successful treatment withdrawal. The criteria impacting this decision are as follows: the risk of relapse (linked to factors like mucosal healing and biomarkers), the consequence of a potential relapse, the tolerance and potential side effects of therapy, patients' priorities and preferences, and the costs. Integration of these parameters allows for the proposal of a decisional algorithm that may help the patients and doctors to make an appropriate decision for their individual case.

Access to High-Cost Biological Agents: Perceptions of Brazilian Patients with Inflammatory Bowel Diseases

“…Several studies have demonstrated a high risk of relapse after stopping biological drugs in IBD, which varies between 20 and 50% at 1 year and between 50 and 80% beyond 5 years. Only a minority of patients may not relapse over the mid-term, and these numbers clearly highlight that we should not stop therapy [ 25 , 26 ].…”

How to handle patients with autoimmune rheumatic and inflammatory bowel diseases in the COVID-19 era: An expert opinion

“…an endoscopic evaluation of mucosal healing), it is possible to rely on calprotectin or CRP levels. Finally, the factors favouring a reduced risk of relapse are immunomodulatory co-treatment, the absence of complex perianal or severe rectal disease, no history of intestinal or colonic stricture, intra-abdominal abscesses or fistulae, and a limited extent of the disease in the past [40]. In the absence of these, it is wiser not to stop biological treatment.…”

TRIP6 promotes inflammatory damage via the activation of TRAF6 signaling in a murine model of DSS-induced colitis

“…The etiological basis for IBD is complex and influenced by a range of host genetic factors, immunological dysfunction, impaired function of the intestinal epithelial barrier dysfunction, and environmental perturbations [ 2 , 3 ]. While a number of anti-inflammatory drugs have been developed to facilitate IBD treatment [ 4 ], the majority of affected patients fail to achieve long-lasting relief. Genome-wide association studies related analyses have led to the identification of many genes associated with IBD susceptibility loci, including NOD2, IL23R, and ATG16L1 [ 5 – 7 ].…”