Introduction Annual audit of steroid use (longer than 3 months or more than 2 courses in the last year), immunomodulator drugs (IM) and anti-TNF is recommended for inflammatory bowel disease (IBD) services. A local audit was carried out to identify the percentage of IBD patients on long term steroids and to ascertain if the use of IM and anti-TNF therapy was appropriate.
Method 396 patients were identified from the IBD register. Of these 77 were excluded (11 moved away, 10 died, 56 not seen in clinic for >12 months). The medical records of the remaining 319 patients (CD 114, UC 182, IBDu 23) were reviewed and relevant data regarding steroid, IM and anti-TNF use was recorded.
Results 152/319 patients (47%) were on regular 5-ASAs and had not received >2 courses or >3 months of steroids in previous 12 months. 37 (11%) were not on any regular medication. The remaining 130 patients (CD 79, UC 43, IBDu 8) had history of steroid, IM or anti-TNF use. Steroid use of >3 months was evident in 14 patients (10.7%). 13 of the 14 had been tried on IM drugs and 1 had declined. 7 patients (5%) received > 2 courses of steroids in 12 months and all had been tried on IM drugs.
126/319 patients (39%) had been started on Azathioprine or Mercaptopurine, but 26 (20.6%) had discontinued due to intolerance. Use of Methotrexate was low; 10 patients (<1%) were currently on treatment, 5 had declined and 2 had previous intolerance.
The number of patients on anti-TNF was relatively small. 35 patients with CD were treated with anti-TNF. Primary non-response was seen in 4 patients (11%), discontinuation due to side effects occurred in 6 (17%) and deep remission in 3 (8.5%) after more than two years of treatment. Infliximab was stopped in the 3 patients in deep remission in accordance with STORI trial criteria.11 had to restart due to relapse after 4 months, the other 2 remain in remission after 7 months.
Conclusion All 21 patients requiring frequent courses or on long term steroids had been offered IM drugs with 95% starting treatment. Optimisation of IM was attempted in all patients with dosing based on weight and TPMT levels. Our strategy has recently changed and we now use 6 TGN levels for dose optimisation with review at the monthly Virtual Biologics and Immunomodulator clinic.
Disclosure of interest None Declared.
Louis E, Mary J-Y, Vernier-Massouille G. Maintenance of remission among patients with Crohn’s disease on antimetabolite therapy after Infliximab therapy is stopped. Gastroenterology 2012;142:63–70