Stopping anti-TNF in CD remitters: pros and cons

Abstract

Background: There is no cure for Crohn’s disease. Available treatments and treatment strategies, particularly anti-TNF, allow to heal intestinal lesions and maintain steroid-free remission in a subset of patients. Having in mind the remitting/relapsing nature of the disease, patients and health care providers often ask themselves whether the treatment could be withdrawn. Several studies have demonstrated a risk of relapse of CD after anti-TNF withdrawal, which varies from 20 to 50% at one year and from 50 to 80% beyond 5 years. These numbers clearly highlight that stopping therapy should not be a systematically proposed strategy in those remitting patients. Summary: Nobody would argue for anti-TNF withdrawal in patients with a high risk of short term relapse. Nevertheless, they also indicate that a minority of patients may not relapse over mid-term and that those who have relapsed may have benefited from a drug-free period before being again treated for a new cycle of treatment. The most relevant question is thus whether in those patients with a low to medium risk of disease relapse, treatment withdrawal could be contemplated. In this specific setting, there may be pros and cons for anti-TNF withdrawal. Amongst the pros are the potential side effects and toxicity of anti-TNF, the risk of loss of response over time, the patient preference allowing the patient to regain control of one’s health and investing in it, also improving adherence, the absence of negative impact on disease evolution of a transient anti-TNF withdrawal and finally the cost. Key messages: Although anti-TNF withdrawal in patients with sustained clinical remission is associated with a high risk of relapse, this risk seems to be much lower in a subgroup of patients, particularly in endoscopic and biologic remission. Stopping anti-TNF in this subgroup of patients may be associated with a favorable benefit/risk ratio.