Scarallo Luca, Bolasco Giulia, Barp Jacopo, Bianconi Martina, di Paola Monica, Di Toma Michele, Naldini Sara, Paci Monica, Renzo Sara, Labriola Flavio, De Masi Salvatore, Alvisi Patrizia, Lionetti Paolo
Gastroenterology and Nutrition Unit, Meyer Children's Hospital, Florence, Italy.
Pediatric Gastroenterology Unit, Maggiore Hospital, Bologna, Italy.
Inflamm Bowel Dis. 2022 Feb 1;28(2):183-191. doi: 10.1093/ibd/izab046.
The aim of the present study was to investigate outcomes of anti-TNF-alpha (ATA) withdrawal in selected pediatric patients with inflammatory bowel disease who achieved clinical remission and mucosal and histological healing (MH and HH).
A retrospective analysis was performed on children and adolescents affected by Crohn disease (CD) and ulcerative colitis (UC) who were followed up at 2 tertiary referral centers from 2008 through 2018. The main outcome measure was clinical relapse rates after ATA withdrawal.
One hundred seventy patients received scheduled ATA treatment; 78 patients with CD and 56 patients with UC underwent endoscopic reassessment. We found that MH was achieved by 32 patients with CD (41%) and 30 patients with UC (53.6%); 26 patients with CD (33.3%) and 22 patients with UC (39.3%) achieved HH. The ATA treatment was suspended in 45 patients, 24 affected by CD and 21 by UC, who all achieved concurrently complete MH (Simplified Endoscopic Score for CD, 0; Mayo score, 0, respectively) and HH. All the patients who suspended ATA shifted to an immunomodulatory agent or mesalazine. In contrast, 17 patients, 8 with CD and 9 with UC, continued ATA because of growth needs, the persistence of slight endoscopic lesions, and/or microscopic inflammation. Thirteen out of 24 patients with CD who suspended ATA experienced disease relapse after a median follow-up time of 29 months, whereas no recurrence was observed among the 9 patients with CD who continued treatment (P = 0.05). Among the patients with UC, there were no significant differences in relapse-free survival among those who discontinued ATA and those who did not suspend treatment (P = 0.718).
Despite the application of rigid selection criteria, ATA cessation remains inadvisable in CD. In contrast, in UC, the concurrent achievement of MH and HH may represent promising selection criteria to identify patients in whom treatment withdrawal is feasible.
本研究旨在调查在部分已实现临床缓解以及黏膜和组织学愈合（MH和HH）的小儿炎症性肠病患者中停用抗TNF-α（ATA）的结果。
对2008年至2018年在2个三级转诊中心接受随访的克罗恩病（CD）和溃疡性结肠炎（UC）患儿及青少年进行回顾性分析。主要结局指标为停用ATA后的临床复发率。
170例患者接受了计划性ATA治疗；78例CD患者和56例UC患者接受了内镜复查。我们发现，32例CD患者（41%）和30例UC患者（53.6%）实现了MH；26例CD患者（33.3%）和22例UC患者（39.3%）实现了HH。45例患者停用了ATA，其中24例为CD患者，21例为UC患者，他们均同时实现了完全MH（CD简化内镜评分分别为0；梅奥评分分别为0）和HH。所有停用ATA的患者均改用免疫调节剂或美沙拉嗪。相比之下，17例患者（8例CD患者和9例UC患者）因生长需求、轻微内镜病变持续存在和/或微观炎症而继续使用ATA。24例停用ATA的CD患者中有13例在中位随访时间29个月后出现疾病复发，而9例继续治疗CD患者中未观察到复发（P = 0.05）。在UC患者中，停用ATA和未停用治疗的患者无复发生存率无显著差异（P = 0.718）。
尽管采用了严格的选择标准，但在CD中停用ATA仍然不可取。相比之下，在UC中，同时实现MH和HH可能是确定可以停用治疗的患者的有前景的选择标准。
