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22. When to stop therapy in Crohn's disease? Results of the EPACT-2 Update panel

V. Pittet1, A. Schoepfer2, M. Maillard2, C. Mottet3, J.-J. Gonvers2, C. Felley4, B. Burnand1, P. Michetti4, F. Froehlich5, J.-P. Vader6, 1Institute of Social & Preventive Medicine, Healthcare Evaluation Unit, Lausanne, 2Centre Hospitalier Universitaire Vaudois, Service de gastro-entérologie et d'hépatologie, Lausanne, 3Hôpital Neuchâtelois, Service de Gastroentérologie, Neuchâtel, 4Clinique La Source, Crohn and Colitis Center, Lausanne, 5Centre Hospitalier Universitaire Vaudois / University Hospital Basel, Service de gastro-entérologie et d'hépatologie, Lausanne / Basel, 6Institute for Social and Preventive Medicine, Health care evaluation unit, Lausanne, Switzerland

Background

Crohn's disease (CD) is a chronic disease with a wide variety of treatment options many of which are not evidence based and many of which are continued for years on end. Supplementing available guidelines, a multidisciplinary European expert panel (EPACT-2) was convened in 2007 to develop explicit appropriateness criteria. Taking advantage of an updating meeting in October 2012, we examine if and when treatment for CD can be withdrawn.

Methods

10 European expert panellists participated the EPACT 2-Update (8 gastroenterologists and 2 surgeons), using the RAND/UCLA appropriateness method. Clinical scenarios reflecting real practice were rated on a 9-point scale from 1 (extremely inappropriate) to 9 (extremely appropriate), based on the experts' experience and the available evidence. All scenarios were re-rated at a one-day panel meeting and consolidated into recommendations of appropriate, uncertain and inappropriate. Elements that informed the decision to withdraw various treatments were presence of clinical and/or endoscopic remission, length of remission (1, 2 or 4 years) and prior surgery for CD.

Results

At the EPACT-2 Update, a total 1030 clinical scenarios were rated. Withdrawing anti-TNF treatment was judged appropriate after 2 yrs in case of clinical (Cr) and endoscopic (Er) remission, and after 4yrs in case of Cr. Stopping azathioprine or methotrexate was judged inappropriate in the first 2 years, irrespective of Cr, CEr or prior history of CD related surgery.

Conclusion

Stopping rules for Crohn's disease treatment were developed for the first time in the framework of guidelines for the appropriate treatment of CD In case of confirmed clinical and endoscopic remission, a trial of withdrawing any treatment was deemed appropriate after 4 years. Explicit appropriateness criteria for therapy of CD were developed and updated that allow both specific therapeutic decision making and prospective assessment of treatment appropriateness.