P346. Short term dose tailoring of anti TNF-α therapy delivers useful clinical efficacy in Crohn's disease patients with secondary loss of response
S. Ghaly1, S. Costello2, L. Beswick3, A. Pudipeddi4, A. Agarwal2, A. Sechi5, B. Headon3, R. Prosser6, S. Connor5, I.C. Lawrance7, M. Sparrow3, P. Bampton6, A. Walsh4, J. Andrews2, 1St. Vincent's Hospital, University of New South Wales, Department of Gastroenterology, Sydney, Australia, 2Royal Adelaide Hospital, Department of Gastroenterology, Adelaide, Australia, 3The Alfred Hospital, Department of Gastroenterology, Melbourne, Australia, 4St. Vincent's Hospital, Department of Gastroenterology, Sydney, Australia, 5Liverpool Hospital, Department of Gastroenterology, Sydney, Australia, 6Flinders Medical Centre, Department of Gastroenterology, Adelaide, Australia, 7Fremantle Hospital, Centre for Inflammatory Bowel Disease, Fremantle, Australia
Dose tailoring of anti TNF therapy in Crohn's disease, by dose escalation or shortening of dosing intervals, may regain clinical response in a proportion of patients. This study examines the impact of dose tailoring on corticosteroid use, the need for surgery and physician perception of clinical efficacy.
This observational multicenter, retrospective study examined the outcomes of dose tailored anti-TNF therapy at six adult teaching hospitals in Australia. Demographics, disease characteristics, medications, indication for, and duration of, dose tailoring and physician's impression of response to treatment were documented.
Fifty-five patients were eligible for inclusion with secondary loss of response being the indication in 96%. Patients had escalation of Adalimumab (64%) or Infliximab (36%) for a median of 5 months (1–47), with a median 20 months (3–65) follow up. By 3 months, dose tailoring led to a drop in the mean number of days on high dose steroids (21 vs 11, p < 0.01) and 73% of physicians reported a good clinical efficacy. At the end of follow up, 78% still remained resection free. De-escalation of therapy was possible in 43 subjects, in 28 this was due to successful induction of remission, failure in 8 and inability to fund ongoing therapy in 5. Of those who de-escalated therapy due to successful induction of remission, long term (>12 months) follow up and complete data on steroid use was available in 17, of these 13 (77%) remained steroid free at one year.
The duration or type of dose tailoring was not predictive of steroid free remission or the need for surgery. Age <30 years was associated with a greater risk of bowel resection despite dose tailoring (OR 5.4, 95% CI 1.27–23, p = 0.02). Absence of prolonged corticosteroid therapy (>6 months) before dose tailoring was predictive of remaining steroid free beyond 12 months (OR 3.5, 95% CI 1.05–12.05, p = 0.04).
Short term dose tailoring will regain response in the majority of patients. Of these most will remain free of corticosteroids at one year even when therapy is de-escalated. Younger patients requiring prolonged steroids appear less likely to benefit.