De-escalation of biological therapy in Inflammatory bowel disease (IBD) and outcomes at week 52: a single centre experience

Introduction

The current NICE guidelines mandate that all patients receiving biological therapy for IBD should have their disease re-evaluated at 12 months, and if the disease is in clinical remission with mucosal healing, treatment can be discontinued. The decision to stop biological therapy should be based on an individual risk benefit assessment. We carried out an audit of our patients who underwent de-escalation, looking at outcomes at week 52.

Methods

All patients on Biologics therapy who underwent biologics de-escalation were identified via our IBD registry. Data was collected retrospectively between January 2015 and January 2022. Baseline demographics, disease type, Biologic therapy and duration, de-escalation therapy, admission and disease relapse at week 52 were analysed.

Results

A total of 62 patients were included and divided in two groups. 37 (60%) patients had Crohn’s disease (CD) and 25 (40%) had Ulcerative Colitis (UC). Demographics across both groups with 54% female and 46% male in the CD group and 40% female and 60% male in the UC group. Disease extent in the CD group included Ileal (32%), Colonic (53%) and Ileocolonic (15%). In the UC group disease extent included Proctitis (12%), Left sided (56%) and Extensive disease (32%). Patients with CD were de-escalated to Mesalazine (3%), Methotrexate (35%), no other medication (3%) and Thiopurines (59%). In UC, patients were de-escalated to Mesalazine (40%), Methotrexate (24%) and Thiopurines (36%). At week 52 14.5% (9) patients had disease reactivation, 13.5% with CD and 16% with UC. of those that had disease recurrence, 77% were diagnosed prior to the age of 40 years. The duration of treatment prior to de-escalation range was 9 to 74 months (Median 47.5). One case required admission for entero-colic fistula and intra-abdominal abscess (antibiotics and exclusive enteral feeding followed by elective resection). One case required a course of steroid. The remaining 7 cases had escalation of therapy (5 re-initiated the original biologic and 2 switched within the class (Anti-TNF)).

Conclusion

In our study, the rate of disease recurrence at week 52 following de-escalation of biological therapy was 14.5%. Those patients with disease onset at a younger age had higher rates of disease recurrence. De-escalation should be discussed with carefully selected patients to discuss the benefit/risk ratio. Our data also showed that disease control can be re-established by reintroducing biological therapy in 77%, but the risk of severe flares, loss of control and developing complications is also significant (10%).