Anti-TNF monotherapy is not inferior to combination therapy in terms of remission and loss of response rates over the long-term in people with IBD.
According to a retrospective audit of 224 patients receiving anti-TNF therapy for IBD in Melbourne, 45% of patients had a loss of response during 8.5 years of follow-up.
Patients were mostly in their late 30s and the majority (90%) had a diagnosis of Crohn’s disease. Most patients were receiving combination therapy (62%) compared to monotherapy (28%) although a higher proportion of patients treated in the private setting received monotherapy.
The audit found loss of response – typically an exacerbation of symptoms – occurred in 59% of patients on combination therapy and 41% of patients on monotherapy.
The median time to loss of response was similar in each group – 1,069 days for combination therapy and 1,489 days for monotherapy.
In the patients who experienced a loss of response, half of those on combination therapy did so within one year of induction compared to 34% of patients on monotherapy.
Loss of response rates and outcomes were similar in patients treated with infliximab and adalimumab monotherapy (50% v 47.5%) and infliximab and adalimumab combinations (40.3% v 45.8%).
Gastroenterologist Dr Poornima Varma, from Monash Health, told the limbic older pivotal trials like SONIC focused on short-term benefits of combination therapy at six months not long-term outcomes.
“The benefit on reduction in immunogenicity to anti-TNF has been shown and does support combination therapy in clinical practice in the short-term, however to show the true benefit of combination therapy beyond this period would require a large study comparing thiopurine naive and experienced patients over a several year period. Only then would one get a true understanding of whether the long-term outcomes in trial setting patients are applicable to the real-world community treated patients.”
“There is no one size fits all with IBD treatment, and combination therapy for one may not necessarily be right for another, particularly the elderly population who are most at risk of skin cancers and infective complications.”
“Current evidence does show early benefit with combination therapy and most clinicians nowadays will start with combination therapy where able but bearing in mind to tailor treatment to each individual as opposed to just following an algorithm.”
“However, the jury is still out on whether combination therapy should be continued or stopped after this 6-12 month period so ongoing management needs to balance clinical remission with prevention of immunosuppressive complications on a case-by-case basis.”