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P392. Outcomes after elective withdrawal of anti-TNF therapy in Crohn's disease: a multicentre study

S. Sebastian1, K. Robinson2, L. Warren3, A. Marsh2, A. Wright2, F. Majeed3, H. Tsai1, A. Brooks2, M.E. McAlindon2, P.J. Hamlin3, A. Lobo2, 1Hull & East Yorkshire NHS Trust, Hull & York Medical School, United Kingdom, 2Sheffield Teaching Hospitals NHS Trust, United Kingdom, 3Leeds Teaching Hospitals NHS Trust, United Kingdom

Background

The impact of stopping anti-TNF therapy for patients in apparent clinical and/or endoscopic remission in routine clinical practice setting is uncertain. We aimed to evaluate clinical outcomes in patients who discontinued anti-TNF therapy electively after at least 12 months of therapy across 3 large centres within Yorkshire & Humber IBD Network, UK.

Methods

Patients with Crohn's disease, whose anti-TNF therapy (62 Infliximab [IFX], 9 adalimumab [ADA]) was stopped electively following a planned assessment were included. All patients had been treated for at least 12 months and followed for at least 3 months after cessation of anti-TNF therapy. Assessment prior to cessation comprised colonoscopy (n = 52), colon capsule (n = 4), MRE (n = 19), Small bowel capsule (n = 5), barium study (n = 2), and clinical assessment (n = 9).

Results

71 patients with Crohn's disease (44 female; median age at diagnosis 24; median duration of disease prior to anti-TNF therapy 21.5 months) were included. Indication for treatment was severe active luminal (n = 50), fistulating perianal (n = 18) and other fistulating disease (n = 3). The median duration of anti-TNF therapy was 18 months (range 12–78). 62 patients (87.3%) continued on immunomodulator therapy following anti-TNF withdrawal.

Relapse rates after 90 days, 180 days and 365 days were 3/71 (4.2%), 5/67 (7.5%), 12/56 (21.4%) respectively. Of those with perianal disease, the relapse rate was 6/18 (33%) at 365 days. All 6 patients who had dose escalation in the 6 months before withdrawal relapsed.

Twenty-five relapsed patients were retreated with anti-TNF agents (9 ADA; 16 IFX), with a response rate of 80% when retreated with same agent as had been withdrawn. 5 patients where IFX was withdrawn responded when retreated with ADA. The overall recapture of response with use of either agent was 84%.

Assessment practice changed after NICE guidance was issued in May 2010; before this 6 of 15 (40%) patients stopping anti-TNF therapy had clinical assessment alone. Only 3 of 56 patients (5.3%) were assessed after that date by clinical assessment alone.

Conclusion

Relapse rates following withdrawal of anti-TNF therapy are lower than previously reported, with a high response rate on retreatment. Patients requiring dose escalation in the 6 months prior to withdrawal may be at higher risk of relapse. We have demonstrated increased endoscopic and radiological assessment prior to withdrawal of anti-TNF therapy. Prospective evaluation of a withdrawal and retreatment strategy for anti-TNF treatment in a larger cohort of Crohn's patients is required.