OP007 Deep remission in Crohn´s disease does not prevent disease relapse after withdrawal of anti-TNFa therapy
M. Bortlik*1, D. Duricová1, N. Machkova1, V. Hruba1, M. Lukas1, K. Mitrova1, I. Romanko1, V. Bina2, M. Lukas1
1ISCARE and Charles University, IBD Clinical and Research Centre, Prague, Czech Republic, 2Faculty of Management in Jindrichuv Hradec, University of Economics in Prague, Department of Exact Methods, Jindrichuv Hradec, Czech Republic
There is an ongoing debate whether cessation of anti- TNFa therapy in Crohn´s disease (CD) patients who are in remission is plausible from the long-term perspective. The aim of our study was to assess the proportion of CD patients who relapse after cessation of biological treatment at the time of endoscopic remission, to identify potential risk factors of disease relapse and to evaluate the risk of development of complicated disease behaviour.
Consecutive patients with CD followed at our centre who discontinued anti- TNFa therapy from 2010 to 2013 were included. At the time of therapy withdrawal all patients had to be in steroid-free clinical remission and all but one were also in endoscopic remission defined as absence of any ulceration. Patients were followed-up prospectively according to predefined protocol. Follow-up visits were scheduled every 2 months during the 1st 6 months and every 3 months thereafter. Relapse was defined as clinical worsening of the disease confirmed by endoscopy and/or imaging procedure or new onset of perianal abscess both leading to change of the medical therapy or surgery.
Sixty one patients were included and followed-up for a median of 28 months (range 7-47). After withdrawal of anti- TNFa therapy (44 infliximab and 17 adalimumab) 47 (77%) patients continued thiopurines. 32 (52.5%) patients relapsed until the end of follow-up with a median time to relapse of 8 months (range 1-25). The cumulative probability of maintaining remission was 82% at 6 months, 59% at 1 year and 51% at 2 years. Analysis of 28 patients who were in deep remission (endoscopic healing; faecal calprotectin <150mg/kg; CRP <5mg/l) revealed no better survival (82%, 64% and 40% at 6 months, 1 and 2 years, respectively). Four (8%) of relapsing CD patients required surgery 5 to 19 months after anti-TNFa cessation (2 for new stricture development, 1 for medically refractory flare and 1 for high grade dysplasia). In multivariate model only disease localization was risk factor of disease relapse (colonic vs. ileal/ileocolonic: OR 0.16, 95%CI: 0.03-0.72; p=0.02). Type of anti- TNFa preparation, smoking, disease behaviour, corticosteroid or thiopurine therapy, biological markers and anti-TNFa trough levels did not impact disease relapse.
Approximately half of CD patients relapsed within 2 years after anti- TNFa discontinuation despite being in endoscopic remission when anti-TNFa was stopped. The highest relapse rate was observed during the 1st year. Ileal disease increased the risk of disease flare, while no other risk factor was identified.
Acknowledgement: This study was supported by IBD-COMFORT foundation.