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P430 European clinician perspective on withdrawing immunosuppression

R. Boyapati1, S. R. Fehily*2, N. S. Ding3

1Monash Medical Centre, Gastroenterology, Melbourne, Australia, 2St Vincent's Hospital, Gastroenterology, Melbourne, Australia, 3St Vincent’s Hospital, Gastroenterology, Melbourne, Australia

Background

Treating to target in inflammatory bowel disease is achieved through early immunosuppression with rapid escalation to combination therapy. Short-term studies support de-escalation to mono-therapy in certain contexts, however long-term outcomes of withdrawing immunosuppression are unknown.1,2 We aimed to assess clinician perspective on, and current barriers to, withdrawing immunosuppression in European practice.

Methods

500 questionnaires were distributed to workshop participants at the 11th Congress of European Crohn’s and Colitis Organisation (ECCO). Likelihood of withdrawing IBD therapies, as well as clinician and patient factors associated with cessation, and barriers to withdrawal were recorded.

Results

Responses were obtained from 132 attendees. 108 clinicians [median age 37 (IQR33–46), 66.7% female] adequately completed surveys from 37 countries with varying levels of clinical experience [median years 6; IQR (3–15)]. Patient–clinician discussion around ceasing immunosuppressive therapy was infrequently raised by both clinicians and patients. The likelihood of ceasing mesalazine monotherapy was greater compared with any biologic agents (p < 0.05), in ulcerative colitis (UC) and Crohn’s disease (CD). The likelihood of ceasing a thiopurine and anti-TNF was similar, however significantly different when compared with vedolizumab and ustekinumab (p < 0.05). The primary reason for ceasing mesalazine was to eliminate unnecessary medications, compared with malignancy and infection risk driving thiopurine and biologic agent cessation. For patients in long-term remission there was great variability in perceived barriers to stopping immunosuppression. Clinician’s reported greater concern about relapse in patients being treated with anti-TNF, vedolizumab, or ustekinumab, compared with mesalazine or immunomodulators (p < 0.001). However, the majority of clinician’s perceived high likelihood of ‘re-capture’ above 50% for all medications.

Conclusion

A reluctance to both de-escalate and cease IBD therapy as part of routine practice prevails across Europe. Further long-term prospective studies are required to evaluate the outcomes of complete immunosuppression withdrawal.

References

1. Boyapati RK, Torres J, Palmela C, et al. Withdrawal of immunosuppressant or biologic therapy for patients with quiescent Crohn’s disease. Cochrane Database Syst Rev 2018;5:CD012540.

2. Van Assche G, Magdelaine-Beuzelin C, D’Haens G et al. Withdrawal of immunosuppression in Crohn’s disease treated with scheduled infliximab maintenance: a randomized trial. Gastroenterology 2008;134:1861–8.