Search in the Abstract Database

Search Abstracts 2011

* = Presenting author

P216. Effectiveness of a dose “de-escalation” strategy with anti-TNF drugs in patients with Crohn's disease (CD)

M. Chaparro1, M. Barreiro2, E. Garcia Planella3, E. Domènech4, F. Bermejo5, X. Calvet6, M. Martín-Arranz7, D. Monfort8, J.P. Gisbert1

1Hospital de la Princesa, Madrid, Spain; 2Hospital Clínico de Santiago, Santiago de Compostela, Spain; 3Santa Creu i Sant Pau, Barcelona, Spain; 4Germans Trias i Pujol, Badalona, Spain; 5Hospital de Fuenlabrada, Madrid, Spain; 6Parc Taulí, Barcelona, Spain; 7Hospital de la Paz, Madrid, Spain; 8Consorci Sanitari de Terrassa, Terrasa, Spain

Background: For patients who lose their initial response to anti-TNF therapy, consideration can be given to dose “escalation” to regain therapeutic benefit. There are both safety and economic concerns with this intensive treatment regimen in the long-term. Therefore, “de-escalation” in dosing could be considered after achieving remission.

Objectives: To evaluate the long-term durability of remission after stepping down the anti-TNF treatment. To identify predictive factors associated with the loss of response with the “de-escalated” treatment. To evaluate the effectiveness of a subsequent anti-TNF dose “escalation” in patients who lose response after stepping down the treatment.

Methods: CD patients who received a “de-escalated” anti-TNF treatment after achieving remission with an “escalated” anti-TNF therapy were evaluated. The disease activity was assessed by the Harvey-Bradshaw activity index. Long-term response maintenance was assessed after stepping down to the standard doses using Kaplan–Meier analysis. Cox-regression analysis was performed to identify potential predictive factors for loss of efficacy.

Results: 24 patients were included (median age 41 years, 50% males, 58% ileocolonic location, 54% inflammatory behaviour). Luminal disease was the indication for the anti-TNF therapy in 58% of patients, perianal disease in 25% and both in 16%. The “de-escalated” anti-TNF drug was infliximab in 63% and adalimumab in 37% of patients. The treatment dosage had been “escalated” due to partial response in 48% of patients, due to loss of response in 42% and due to primary non-response in 10%. Immunossuppresants were maintained in 58% of patients after the “de-escalation”. The median time in remission before the “de-escalation” was 7 months. The median time of follow-up with the “de-escalated” dose of anti-TNF treatment was 7 months (range:3–44 months). The incidence rate of loss of response after the “de-escalation” was 40% per patient-year of follow-up. The cumulative incidence of loss of response was 32%, 42% and 71% at 12, 18 and 24 months with “de-escalated” therapy. The dose of the anti-TNF drug was “escalated” again in all patients who lost response. 38% percent of patients did not respond, 25% had partial response and 37% reached remission. Predictive factors of loss of response with the “de-escalated” treatment were not found in the multivariate analysis.

Conclusions: (1) A high proportion of CD patients who are in remission with an “escalated” dose of anti-TNF drug seems to lose response after the “de-escalation” of the treatment (40% per patient-year). (2) Two-third of patients who lose remission after the “de-escalation” cannot achieve it again after the new dosage “escalation”. (3) Predictive factors of relapse after “de-escalation” have not been identified; therefore, patients who can benefit from the “de-escalation” estrategy cannot be selected.