Optimising IBD patient selection for de-escalation of anti-TNF therapy to immunomodulator maintenance.

OBJECTIVE

Inflammatory bowel disease (IBD) is increasingly managed with the use of biologic therapies. National guidelines (National Institute for Health and Care Excellence (NICE)) suggest considering cessation after 1 year of therapy but lack detailed criteria for this. We aimed to describe clinical outcomes from the introduction of a biologic review panel (BRP) to implement modified criteria for cessation of antitumour necrosis factor (anti-TNF) therapy and step down to single-agent immunomodulator.

DESIGN

Retrospective review of patient outcomes following BRP implementation.

PATIENTS

All patients on biologic therapy discussed in the BRP within a 5-year period.

SETTING

Single IBD network covering three hospital sites.

INTERVENTIONS

Modified criteria for biologic cessation were based on published evidence; they excluded individuals with no suitable maintenance immunomodulator, previous surgery or evidence of active disease, additional indications for anti-TNF therapy and previous relapse on biologic cessation. All patients with IBD on a biologic were discussed at the BRP.

MAIN OUTCOME MEASURES

Relapse following IBD cessation and relative cost of BRP.

RESULTS

136 patients with IBD were reviewed, with 45 patients meeting the NICE guideline criteria for cessation. The BRP and modified criteria affected decision to withdraw therapy in 38% of these. Therapy was withdrawn in 27 patients, with a 20% 24-month relapse rate. Younger age at cessation was significantly associated with relapse (p=0.01).

CONCLUSION

The BRP approach has proved a safe and effective means of decision making in stopping biologic therapy. Future work to inform exclusion criteria is required.