Stopping Anti-TNF Agents in Patients with Crohnʼs Disease in Remission

Abstract

Crohn's disease (CD) is a chronic inflammatory disorder whose incidence is on the rise. Its relentless course often leads to surgery if the disease is left untreated. CD etiology is unknown and as such, it cannot be cured. As it is often the case with such conditions, the next best option to keep the disease under control is to suppress inflammation.1 Today's therapeutic armamentarium for CD includes steroids, antibiotics, immunomodulators (IM) and biologics. The latter, in most countries, only include tumor necrosis factor (TNF) neutralizing agents (infliximab, adalimumab, and certolizumab), by far the most effective agents. As in other chronic diseases, medical treatment must be life long to keep inflammation under control. Stopping therapy, by definition, is expected to cause quick relapse of inflammation. Yet, recent clinical data have partly challenged this basic assumption in the management of CD. Here, we will first review the original data suggesting that medical therapy with anti-TNF agents must be continuous to be effective in the long term. We will then review more recent data that indicate that anti-TNF agents may be stopped in a proportion of patients in remission without a major impact on disease control; the risk factors associated with relapse on stopping therapy and the likelihood of reinducing remission with the same medication in relapsing patients. Next, we will focus on the potential biological and clinical implications of these observations and discuss possible alternative long-term options in CD management.