Introduction Anti-TNF therapy (ATT) is increasingly used in Crohn's disease (CD) in the UK. However, because of its expense, NICE guidance recommends that after a year of treatment, responders should be reassessed and withdrawal of treatment considered if they are in remission. We report our experience in a tertiary referral centre of reassessment after 1 year of ATT and of factors leading to continuation or withdrawal of treatment.
Methods We performed a 12-month retrospective review of patients with CD who had received ATT for >12 months by 31 December 2011. Reassessment was defined as having undergone one or more of the following investigations aimed at assessing disease activity: endoscopy, examination under anaesthesia, MRI or faecal calprotectin (FC). Results of investigations and outcome were recorded.
Results 91 patients (infliximab n=55, adalimumab n=36) were included of whom 80% (73/91) had their disease reassessed. Five patients were withdrawn from treatment (of whom one has already relapsed) and five are pending trial of withdrawal; two patients met criteria for withdrawal but required continuation for extra-luminal disease such as arthropathy. 84 (92%) continued therapy. 48 patients had endoscopic reassessment; mucosal healing (MH) was demonstrated in 25% (n=12), non-ulcerating inflammation in 40% (n=19) and ulceration in 35% (n=17). Of 12 with MH 3 withdrew from therapy and 3 are pending withdrawal. Of six patients who continue, two require ongoing ATT for arthropathy, three had radiologic evidence of activity, and one is undergoing further assessment. 24 patients had both endoscopy and MRI and 19 patients underwent MRI alone. Of the latter group, scans were normal in 21% (n=4), showed improvement but not resolution in 32% (n=6) and active disease in 47% (n=9). Of four normal scans, one patient was withdrawn, and 3 continue due to raised FC (n=1) or raised CRP (n=2). Disease was assessed by EUA in five patients, demonstrating active disease in four and quiescent disease in one who is pending trial of withdrawal. One patient continues on treatment on the basis of raised FC alone. One patient had mild mucosal inflammation on endoscopy and an unchanged MRI scan prior to withdrawal but relapsed within 4 months.
Conclusion Reassessment after at least 12 months of ATT showed ongoing disease activity in the vast majority (84%). Withdrawal was considered appropriate in only 13%. In patients with distal ileal and/or colonic disease, endoscopy is currently our mainstay of reassessment while for those with small bowel disease interval change on MRI is used. The role of CRP and FC remain to be defined.
Competing interests None declared.
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