Ben-Horin Shomron, Mao Ren, Qiu Yun, Chen Minhu
Department of Gastroenterology, Sheba Medical Center, Tel-Aviv University, Tel Hashomer, Israel.
Department of Gastroenterology, 1st Affiliated hospital of Sun-Yatsen University, Guangzhou, China.
J Clin Gastroenterol. 2018 Jan;52(1):6-12. doi: 10.1097/MCG.0000000000000938.
Despite the proven efficacy of biological drugs for inflammatory bowel disease, these therapies are costly and do carry some risks, providing incentive for exploring strategies to discontinue therapy in patients with prolonged remission. We presently review multiple cohort studies indicating the overall risk of relapse after stopping an anti-tumor necrosis factor (TNF) in inflammatory bowel disease patients is roughly 40% at 12 months after therapy cessation. Despite methodological differences across studies, it appears that patients without deep remission (ie, patients with endoscopic or biomarker evidence of inflammation) are at increased risk of relapse after stopping anti-TNF, as are those with high-adequate levels of anti-TNF before stopping. In patients who relapse after anti-TNF cessation, retreatment with the same biological seems to reinduce clinical response in most patients. Immunological reasons responsible for this high success rate for retreatment are elucidated, but resorting to retreatment also implies a small but finite risk of a severe flare leading to surgery, which should be borne in mind. Thus, stopping attempts should probably be reserved for patients with low risk for severe outcome should a relapse occur. Proactive endoscopic monitoring after drug cessation is imperative to reduce these risks. The recently introduced concept of treatment-cycles is discussed, along with a pragmatic algorithm of decision tree for therapy discontinuation in the selected appropriate patients.
尽管生物药物对炎症性肠病的疗效已得到证实，但这些疗法成本高昂且确实存在一些风险，这促使人们探索在长期缓解的患者中停止治疗的策略。我们目前回顾了多项队列研究，结果表明，炎症性肠病患者停用抗肿瘤坏死因子（TNF）后，在停药后12个月时复发的总体风险约为40%。尽管各项研究在方法上存在差异，但似乎未达到深度缓解的患者（即有内镜或生物标志物炎症证据的患者）在停用抗TNF后复发风险增加，在停药前抗TNF水平较高的患者也是如此。在停用抗TNF后复发的患者中，再次使用相同的生物制剂进行治疗似乎能在大多数患者中再次诱导临床反应。虽然导致这种再治疗高成功率的免疫学原因已得到阐明，但采用再治疗也意味着有小但确切的严重病情加重导致手术的风险，应牢记这一点。因此，停药尝试可能应仅限于复发时严重后果风险较低的患者。停药后进行积极的内镜监测对于降低这些风险至关重要。本文还讨论了最近引入的治疗周期概念，以及为选定的合适患者制定的实用的停药决策树算法。
