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P491. How are common treatment issues in patients with anti-TNF therapy addressed in real life? Results from a survey among Swiss gastroenterologists

L. Biedermann1, S. Radivojevic2, A. Schoepfer3, G. Rogler1, S. Vavricka2, 1University Hospital Zurich, Division of Gastroenterology & Hepatology, Zurich, Switzerland, 2Triemli Hospital, Division of Gastroenterology & Hepatology, Zurich, Switzerland, 3University Hospital Lausanne, Division of Gastroenterology & Hepatology, Lausanne, Switzerland

Background

In recent years several trials have been published with regards to anti TNF-therapy in Crohn's disease (CD) addressing treatment-optimisation for better remission and response rates, minimisation of toxicity and prevention of both over- and under-treatment. The questions on the optimal strategy if treatment escalation is needed and how a loss of response (LOR) to anti-TNF should be addressed have been intensively discussed. Switzerland is the only country aside from the US, where 3 TNF- inhibitors (infliximab – IFX, adalimumab – ADA and certolizumab – CTZ) are presently approved for the treatment of CD. Using a questionnaire we aimed to investigate, how these aforementioned treatment issues in CD patients under anti-TNF are addressed in clinical practise by Swiss gastroenterologists.

Methods

A questionnaire including 6 main questions and a basic section with regard to personal information was sent to all gastroenterologists in Switzerland.

Results

The vast majority of all Swiss GI specialists (90%) use a thiopurine as the first step up strategy after steroids and not anti-TNF- (7.5%) or combo-therapy (2.5%) up front. While 41.2% of all Swiss gastroenterologists state to have no specific preference for any TNF-inhibitor, IFX is the favourite anti-TNF agent in 47.1% (ADA 10.9% and CTZ 0.8%). IFX is even significantly more preferred in those seeing less than 30 IBD patients per year (57.4%; >30. Pat 36.2%, p = 0.02). To address LOR the most preferred strategy is shortening the interval of anti-TNF administration in 49.5% of doctors (mean 5.4 on a scale from 1 to 6; lowest and highest agreement, respectively), followed by increasing the dose (5.0), switching the TNF-inhibitor (4.9), add a thiopurine (3.9), initiate a full re-induction (3.6), add prednisone (3.5), refer to surgery (3.5) and add methotrexate (2.9). In case of prolonged remission on combo therapy Swiss gastroenterologists stop one drug after a mean of 15.7 month (with a fairly wide range from 6 to 48 month). The thiopurine is stopped first in most cases (50.8%; TNF-inhibitor first 40%, only 4.2% continue both therapies, stop both at the same time 1.7%, other 3.3%).

Conclusion

In the case of LOR dose intensification prior to switching of the TNF-inhibitors is most often used among Swiss gastroenterologists. Regarding step-up and de-escalation strategies GI specialists in Switzerland still mainly apply a conventional step-up with thiopurines. In the case of prolonged remission, stopping the immunosuppressant first is preferred.