P514 Need for anti-TNF escalation in Inflammatory Bowel Disease - A single center experience
S. Fernandes*, C. Moura, P. Santos, P. Sousa, L. Correia, P. Moura Santos, A. Valente, A. Rita Gonçalves, C. Baldaia, N. Fatela, F. Serejo, J. Velosa
Centro Hospitalar Lisboa Norte, Gastrenterology, Lisbon, Portugal
Anti-TNF therapy has become the standard of care in patients with moderate to severe Ulcerative Colitis(UC) and Crohn's Disease(CD). However, patients who initially respond may lose efficacy over time. Treatment escalation by increasing dosage or shortening intervals between administrations has proven to be effective in regaining response.
Our primary goal was to compare the need and time until anti-TNF escalation in patients with CD and UC. We also evaluated potential predictors of the need for treatment escalation.
We retrospectively reviewed patients followed in our institution under maintenance therapy with Infliximab (IFX) or Adalimumab (ADA). Patients not responding to induction therapy or with a history of previous failure to another anti-TNF were excluded. Statistical analysis was performed using SPSS v 20.0
203 patients (175 CD, 28 UC) met our inclusion criteria. IFX was prescribed in 144 patients (122 CD, 22 UC) and ADA in 59 patients (53 CD, 6 UC). Except for a higher prevalence of perianal disease in CD patients under IFX, baseline characteristics were similar between groups. 48/127 (37.8%) CD and 13/28 UC (46.4%) required therapy escalation (p=0.042). This was not associated with the type of anti-TNF used (p=0.350 and p=0.843 respectively for IFX and ADA) or with concurrent immunomodulation (p=0.157). Overall, patients with CD were younger at the time of first infusion (36.4 ± 14.2 years versus 42.9 ± 14.4 years, p=0.032) and time until escalation was shorter in patients with UC (1.0 ± 0.8 years versus 3.3 ± 2.6 years, p=0.003). The cumulative probability of avoiding escalation was higher in CD patients (Breslow exact test, p=0.002; p=0.006 if adjusted for type of anti-TNF). Predictors associated with the need to escalate anti-TNF included a positive C-reactive-protein (p< 0.0001), moderate to severe inflammation at baseline endoscopy (SES-CD > 11, Mayo > 2, p= 0.027) and a drop in hemoglobin levels in patients with anemia at induction (p=0.04).
Treatment failure is a common event in patients under anti-TNF therapy. Dose intensification occurs earlier and more frequently in patients with UC independently of the anti-TNF used. C-reactive-protein, endoscopic scores and hemoglobin levels may be useful in predicting earlier need for escalation.