The great debate: stopping immunomodulators and biologics in Crohn's disease patients in remission

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Date: Aug. 2013
Publisher: Expert Reviews Ltd.
Document Type: Editorial
Length: 1,434 words
Lexile Measure: 1520L

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Author(s): Jana G Hashash 1 , Miguel D Regueiro [*] 2



anti-TNF therapy; immunomodulator therapy; predictors of relapse

Lifelong immunosuppression for Crohn's disease has been associated with increased morbidity; opportunistic infections, lymphomas, nonmelanoma skin cancers and allergic/hypersensitivity reactions [1] . Many Crohn's disease patients are on combination therapy with an immunomodulator and anti-TNF medication. It is unclear what happens when Crohn's disease treatment is stopped in patients who have achieved remission. Several studies have investigated the outcomes of stopping immunomodulator therapy or anti-TNF therapy in patients who successfully achieve remission.

Predictors of relapse

Predictors of which patients would relapse and which would remain in remission once Crohn's disease medications are stopped would be powerful information for physicians treating inflammatory bowel disease (IBD) patients. There have been several studies that tried to identify such predictors of relapse. Louis et al . aimed at identifying predictive factors for relapse after discontinuation of infliximab therapy [2] . Variables associated with a high risk for relapse included male gender, absence of prior resection, active smoking and the presence of active Crohn's disease as identified by a hemoglobin level of [less than or equal to]145 g/l, fecal calprotectin level [greater than or equal]300 µg/g, white blood cell count >6 × l109 /l and a Crohn's disease endoscopic index of severity (CDEIS) of [greater than or equal]2 [2] . Another study by Molnar et al . also assessed the predictors of Crohn's disease recurrence after discontinuation of anti-TNF therapy [3] . Active smoking, use of steroids at initiation of anti-TNF therapy, a prior need for biologic therapy, biologic therapy dose intensification and an elevated C-reactive protein (CRP) level at initiation of anti-TNF therapy were found to be predictors for clinical recurrence and the need to restart biologic therapy [3] . Finally, Oussalah et al . studied the predictors for infliximab failure in Crohn's disease patients whose azathioprine was discontinued after they were treated with combination infliximab and azathioprine [4] . A multivariate analysis identified that a platelet count >298 × 10 9 /l, CRP >5 mg/l and a duration of [less than or equal to]811 days of infliximab-azathioprine combination therapy were all considered predictors of infliximab failure in patients who had their...

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Gale Document Number: GALE|A341859526