Department of Medicine, Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, CA, USA.
Department of Medicine, Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.
J Crohns Colitis. 2020 Oct 5;14(10):1413-1423. doi: 10.1093/ecco-jcc/jjaa087.
We conducted a systematic review and meta-analysis evaluating the relapse rate after therapeutic de-escalation in inflammatory bowel disease [IBD] patients who achieved deep remission [DR].
We searched MEDLINE, EMBASE, and major gastroenterology conferences up to July 2019 for studies reporting relapse in adult patients with DR who subsequently underwent therapeutic de-escalation. Eligible studies defined DR as at least a combination of clinical remission and mucosal healing/endoscopic remission. The primary outcome was cumulative 1-year and 2-year relapse rates after therapeutic de-escalation. Secondary outcomes were relapse rates in ulcerative colitis [UC] and Crohn's disease [CD], relapse after anti-tumour necrosis factor-α [anti-TNFα] de-escalation, and the rate of disease response recapture following re-escalation.
Thirteen studies encompassing 837 patients were identified. The cumulative relapse rate after therapeutic de-escalation was 28.7% within 1 year [12 studies], and 38.4% within 2 years [eight studies]. Relapse rates within 1 year and 2 years were comparable between UC [five studies; 25.4% and 37.4%] and CD [seven studies; 34.1% and 39.9%]. Ten studies reported de-escalation of anti-TNFα, of which 29.8% patients relapsed within 1 year and 41.4% within 2 years. Response recapture following re-escalation [eight studies] was 75.4%.
Despite achieving deep remission, therapeutic de-escalation in this patient population is associated with significant relapse risk within 1 year and 2 years. This risk is more pronounced in patients requiring anti-TNFα for management, likely because of more severe disease. Similar rates of relapse were reported among UC and CD within these time periods. These findings suggest that combined clinical and endoscopic remission should not be an impetus to consider therapeutic de-escalation.
我们进行了一项系统评价和荟萃分析，评估在达到深度缓解（DR）的炎症性肠病（IBD）患者中进行治疗降级后复发的发生率。
我们检索了 MEDLINE、EMBASE 和主要的胃肠病学会议，截至 2019 年 7 月，以寻找报告在 DR 后接受治疗降级的成年患者中复发情况的研究。符合条件的研究将 DR 定义为至少联合临床缓解和黏膜愈合/内镜缓解。主要结局是治疗降级后 1 年和 2 年的累积复发率。次要结局是溃疡性结肠炎（UC）和克罗恩病（CD）的复发率、抗肿瘤坏死因子-α（抗-TNFα）降级后的复发率，以及重新升级后的疾病缓解率。
共确定了 13 项包含 837 例患者的研究。治疗降级后 1 年内的累积复发率为 28.7%（12 项研究），2 年内为 38.4%（8 项研究）。UC（5 项研究；1 年内 25.4%，2 年内 37.4%）和 CD（7 项研究；1 年内 34.1%，2 年内 39.9%）之间的 1 年和 2 年的复发率相似。10 项研究报告了抗-TNFα的降级，其中 1 年内有 29.8%的患者复发，2 年内有 41.4%的患者复发。重新升级后的缓解率为 75.4%（8 项研究）。
尽管达到了深度缓解，但在该患者人群中进行治疗降级与 1 年内和 2 年内的显著复发风险相关。在需要抗-TNFα治疗的患者中，这种风险更为明显，可能是因为疾病更严重。在这些时间段内，UC 和 CD 的复发率相似。这些发现表明，联合临床和内镜缓解不应成为考虑治疗降级的动力。
