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P467. How often do we discontinue maintenance infliximab due to clinical remission in Crohn's disease?

S.J. Budas, J.P. Seenan, N. Jamieson, A. Cahill, J.W. Winter, D.R. Gaya, A.J. Morris, Glasgow Royal Infirmary, Gastroenterology, Glasgow, United Kingdom

Background

Biologics are increasingly used as maintenance treatment in the management of Crohn's disease (CD). UK guidelines [1] advise reassessing CD patients after 12 months of treatment with infliximab and discontinuing therapy for patients in stable clinical remission. Evidence suggests that sustained remission may be achieved in up to 50–60% of these patients on withdrawal of treatment [2]. However, it is recognised that decisions regarding continuing treatment must be individualised and take into account previous disease behaviour. We sought to determine how often in clinical practice maintenance infliximab was discontinued due to clinical remission.

Methods

All patients treated with infliximab for CD between September 2006 and January 2013 were identified from our inflammatory bowel disease (IBD) database. Dates of initiation and termination of treatment were recorded along with the reason for discontinuation. Patients continuing on infliximab were analysed in more detail. Patient demographics, past medical history, Montreal classification and faecal calprotectin (FC) levels were recorded.

Results

161 patients were identified. 11 patients transferred care and were excluded. 127/150 (84.7%) received maintenance (>6 weeks) treatment. 63/127 (49.6%) had discontinued treatment while 64/127 (50.4%) remained on treatment. The median length of treatment was 79 weeks (range 8–329). Only 27% (17/63) discontinued infliximab due to clinical remission with 33.3% (21/63) stopping because of complications and 38.1% (24/63) due to loss of response, surgery or death. The median course of treatment for those continuing infliximab was 109.6 (range 8–329) weeks. 48 patients (25 male, mean age 39 years) were on maintenance infliximab treatment for over 1 year. 77.1% of these patients were on combined treatment with an immunomodulator and 39.6% (19/48) had required dose escalation or a reduction in dose interval. 10/48 (20.8%) were current smokers. In patients continuing treatment for over 1 year, the median FC was 177 µg/g (range 30–9000).

Conclusion

In our large cohort of CD patients, few patients discontinued infliximab due to clinical remission. The majority of patients who require prolonged maintenance therapy (>1 year) are co-prescribed immunomodulators and dose intensification is often required. A significant proportion continue to smoke. Despite this, the median FC of those continuing therapy is low suggesting good control of inflammation.

1. Mowat C, Cole A, Windsor A, Ahmad T, Arnott I, Driscoll R et al., (2011), Guidelines for the management of inflammatory bowel disease in adults., Gut, 571–607, 60 (5).

2. Louis E, Mary JY, Vernier-Massouille G, Grimaud JC, Bouhnik Y, Laharie D et al., (2012), Maintenance of remission among patients with Crohn's disease on antimetabolite therapy after infliximab therapy is stopped., Gastroenterology, 63–70, 142 (1).