© Springer International Publishing Switzerland 2015
Daniel J. Stein and Reza Shaker (eds.)Inflammatory Bowel Disease10.1007/978-3-319-14072-8_1212. Can I Stop My Medications Now that I Am Feeling Well? Why Maintenance Therapy Is Important in Preventing Recurrence in Crohn’s Disease
(1)
Division of Gastroenterology and Hepatology, Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI 53226, USA
Keywords
Crohn’s diseaseUlcerative colitisAzathioprineThiopurinesInfliximabAnti-TNFCombination therapySuggested Response to the Patient
It is important to understand that although you may be feeling well while taking medication for your Crohn’s disease, we have not cured you of Crohn’s disease. At this time we are only controlling your disease. As of right now we have only limited information on what happens when we stop medications for Crohn’s disease. The limited information we do have seems to show that Crohn’s disease will have a high likelihood of coming back if we were to stop your medications. While it may take a year or more for the Crohn’s disease to come back, it will recur in most patients that stop their therapy. Also when your disease comes back, there is no guarantee that restarting the medications will work when they are restarted. For this reason it is important to continue on your current therapy that has been successful at inducing and maintaining your remission.
Brief Review of the Literature
Reasons for Discontinuation
Crohn’s disease and ulcerative colitis are chronic, lifelong diseases that have no known medical cure at this time. However, effective immunosuppressive therapy has become the mainstay of inducing and maintaining remission in IBD patients. It has been shown in both Crohn’s disease and ulcerative colitis that combination therapy with thiopurines and infliximab is more effective than either one alone to achieve clinical and endoscopic remission [1, 2]. Therefore, we have effective therapy to treat patients with IBD.
However, patients who achieve remission no matter how it is defined frequently ask if their immunosuppression can be stopped or reduced. This may occur for any number of reasons including: potential for infection, potential for malignancy, newly diagnosed malignancy, cost of the medication, pregnancy, intolerance, or desire to take a drug “holiday” to name a few. Clearly patients suffering from a serious complication related to the immunosuppression should have their therapy held. What about the patients that are doing well and are not having a complication of their therapy? Is it safe to withdraw or reduce therapy in this population? These are the questions this chapter will attempt to answer.
Given the limited data on withdrawal of medications and that the two conditions respond similarly to immunosuppression, this chapter will review the literature for both UC and CD.
Dose Reduction of Thiopurines
The therapeutic benefit of combination therapy is largely thought to be a result of increased anti-TNF trough levels and decreased levels of immunogenicity to the anti-TNF antibodies. There have not been any studies investigating dose reduction of thiopurines in IBD patients on combination therapy or monotherapy. However, it has been reported that higher 6-thioguanine levels, but not thiopurine dose, are associated with higher tough levels of infliximab suggesting dose reduction may be possibly in the setting of high 6-thioguanine levels [3].
Dose Reduction of Biologics
There is very little evidence to discuss when it is safe to decrease the dose of biologics in IBD patients. One part of the TAXIT trial decreased the frequency of infliximab infusion based on elevated infliximab levels without effect on disease remission rates [4]. Adalimumab de-escalation was also evaluated in patients that had achieved clinical remission on weekly dosing. Decreasing the adalimumab dosing from every week to every 2 weeks was only successful in 47 of the 75 patients (63 %) after 6 months [5]. Decreasing the dose of anti-TNF therapy should not be done routinely, but patients in remission with elevated trough levels of infliximab could be considered for dose reduction.
Discontinuation of Immunomodulator Monotherapy
There have been several trials looking at the discontinuation of immunomodulator (azathioprine or 6-mercaptopurine) therapy in both UC and CD. A randomized controlled trial in UC looking at stopping azathioprine showed that the relapse rates at 1 year were 36 and 59 % in patients taking AZA and placebo, respectively (P = 0.039) [6]. Additionally, a retrospective observational study showed a relapse rate of approximately one third, one half, and two thirds in UC patients in steroid-free remission who stopped their azathioprine at 1-, 2-, and 3-year follow-up, respectively [7].
Similarly in CD, a placebo-controlled trial looking into azathioprine withdrawal found relapse rates of 14, 53, and 63 % at 1, 3, and 5 years, respectively, for patients having stopped azathioprine [8]. Additionally a large meta-analysis on relapse rate in patients stopping azathioprine monotherapy showed similar findings [9]. Overall patients that are doing well on their immunomodulator therapy should be continued on their therapy unless a serious side effect or contraindication develops.
Discontinuation of Biologic Monotherapy
Currently there are no trials looking at stopping anti-TNF monotherapy in a randomized placebo-controlled fashion. However, we know from the clinical trials that were designed to look at anti-TNF therapy efficacy that patients randomized to placebo after induction therapy were significantly more likely to have disease recurrence than those continued on anti-TNF therapy [10, 11]. For this reason continuing maintenance therapy with anti-TNFs monotherapy in patients doing well is recommended.
Related posts:
What Factors of My Crohn’s Disease Put Me at Higher Risk of Complications? Identifying Crohn’s Patients with Severe Disease
Why Did This Happen to Me? Epidemiology, Genetics, and Pathophysiology of IBD
Why Can’t I Continue to Take My Narcotics? The Long-Term Negative Effects of Narcotics
What Is the Best Therapy for My Moderate to Severe Ulcerative Colitis? State-of-the-Art Therapy for Moderate to Severe Ulcerative Colitis
Is It Safe for Me to Breastfeed While on My IBD Medications? Safety of Lactation and IBD Medications
Does Stress Play a Role in My Disease? The Role of Stress and Psychiatric Issues in IBD
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