Stopping Anti-TNF in Crohn's Disease Remitters: Pros and Cons: The Pros.

BACKGROUND

There is no cure for Crohn's disease (CD). Available treatments and treatment strategies, particularly anti-TNF, allow healing intestinal lesions and maintaining steroid-free remission in a subset of patients. Having in mind the remitting/relapsing nature of the disease, patients and health care providers often ask themselves whether the treatment could be withdrawn. Several studies have demonstrated a risk of relapse of CD after anti-TNF withdrawal, which varies from 20 to 50% at 1 year and from 50 to 80% beyond 5 years. These numbers clearly highlight that stopping therapy should not be a systematically proposed strategy in those remitting patients.

SUMMARY

Nobody would argue for anti-TNF withdrawal in patients with a high risk of short-term relapse. Nevertheless, they also indicate that a minority of patients may not relapse over midterm and that those who have relapsed may have benefited from a drug-free period before being again treated for a new cycle of treatment. The most relevant question is thus whether in those patients with a low to medium risk of disease relapse, treatment withdrawal could be contemplated. In this specific setting, there may be pros and cons for anti-TNF withdrawal. Among the pros are the potential side effects and toxicity of anti-TNF, the risk of loss of response over time, the patient preference allowing the patient to regain control of one's health and investing in it, also improving adherence, the absence of a negative impact on disease evolution of a transient anti-TNF withdrawal, and finally the cost.

KEY MESSAGES

Although anti-TNF withdrawal in patients with sustained clinical remission is associated with a high risk of relapse, this risk seems to be much lower in a subgroup of patients, particularly in endoscopic and biologic remission. Stopping anti-TNF in this subgroup of patients may be associated with a favorable benefit/risk ratio.