Perianal CD relapse after stopping anti-TNF

March 25, 2024

Issue 07

Clinical Question

How likely is perianal disease relapse after discontinuing successful anti-TNF treatment?

Editor’s Bottom Line

Rates of relapse among patients with perianal Crohn’s disease who discontinue anti-TNF therapy are high, and mirror rates among patients with luminal Crohn’s disease. These data will help to counsel patients considering treatment de-escalation.

Reference

Ten Bokkel Huinink S, Thomassen D, Steyerberg EW, et al. Discontinuation of Anti-Tumour Necrosis Factor Therapy in Patients with Perianal Fistulizing Crohn’s Disease: Individual Participant Data Meta-Analysis of 309 Patients from 12 Studies. J Crohns Colitis. 2024 Jan 27;18(1):134–43; https://academic.oup.com/ecco-jcc

Synopsis

This was a multicenter systematic review of 12 published cohort studies examining the incidence of relapse following anti-TNF discontinuation in patients with perianal Crohn’s disease (CD).

The 309 individuals included in the study were 16 years or older, 45% were male and all had perianal CD as an indication for initiating anti-TNF therapy. All had been administered at least four doses of the anti-TNF, which in 84% of cases was infliximab, and all had achieved radiological and clinical remission of luminal and perianal disease prior to anti-TNF discontinuation. While all had active perianal disease, 11% also had active luminal disease at the start of anti-TNF treatment.

Where available, the authors also obtained individual participant data from the original study cohorts.

The median duration of anti-TNF treatment was 14 months [Interquartile Range [IQR]: 5.8–32.5] and the median follow-up after discontinuation was 29 months [IQR:12–62 months]. In 78% of cases, patients received immunosuppressive therapy after discontinuing anti-TNF treatment.

Analyses showed that 54% of patients experienced disease relapse a median 11 months after anti-TNF discontinuation. Relapse rates at one and two years were 36% (95% Confidence Interval [CI]: 25–48%) and 42% (95% CI: 32–53%), respectively.

Forty-five percent of patients experienced perianal disease relapse after a median 11 months of post-discontinuation follow-up [IQR: 2.8–24.3], with 77% of these individuals experiencing relapse of perianal fistulae and 21% having both perianal fistulizing relapse and anal abscess. Fifteen percent experienced relapse of both perianal and luminal CD, while 19% experienced luminal disease relapse alone.

Statistically significant risk factors for relapse included smoking (Hazard Ratio [HR]: 1.5; 95% CI: 1–2.1) and a history of proctitis (HR: 1.7; 95% CI: 1.1–2.5]).

For those who were retreated with an anti-TNF after relapsing post-discontinuation, 82% had regained response a median 3.5 years after retreatment. Eighty-five percent of these patients were treated with the same anti-TNF they had discontinued.

Details

Study Design: Meta-analysis
Funding: None
Allocation: None
Setting: Multicenter
Level of Evidence: 1a