Optimized thiopurine therapy before withdrawal of anti-tumour necrosis factor-α in patients with Crohn’s disease

• DOI: 10.1097/meg.0000000000001194
• Publication Date: 2018-07-03T15:17:36Z
• Authors: Sandra Bohn Thomsen; Marianne Kiszka-K...; Klaus Theede; Lise Lotte Gluud; Anette Mertz Nielsen
• Keywords: Adult; Male; 6-thioguanine; Feces; Young Adult; 03 medical and health sciences; 0302 clinical medicine; Crohn Disease; Gastrointestinal Agents; inflammatory bowel disease; Recurrence; Humans; Thioguanine; azathioprine; Mercaptopurine; Tumor Necrosis Factor-alpha; Adalimumab; Anti-tumour necrosis factor-α therapy; Infliximab; 3. Good health; Crohn's disease; Withholding Treatment; Female; Leukocyte L1 Antigen Complex; Immunosuppressive Agents

Objective Two meta-analyses have found that the risk of relapse in Crohn’s disease (CD) was ~40 and 50% 1 and 2 years, respectively, after withdrawal of anti-tumour necrosis factor-α (anti-TNFα). The aim of this study was to evaluate relapse rates in CD when thiopurine therapy was optimized before anti-TNFα withdrawal.

Patients and methods An observational study was conducted including patients with CD in remission with optimized thiopurine therapy before anti-TNFα withdrawal. We defined optimized thiopurine therapy as 6-thioguanine levels of at least 150 nmol/mmol haemoglobin (∼300 pmol×108 red blood cells) and clinical/biochemical remission as Harvey-Bradshaw Index of 5 or less and faecal calprotectin of 200 µg/g or less.

Results We included 33 patients (median age: 31 years, 55% males, and median disease duration: 7 years) followed for a median of 36 months. A total of three (9%) patients relapsed during the first year and six patients (in total 27%) relapsed after 2 years. After 2 years, none of the additional patients relapsed. The disease duration and duration of anti-TNFα treatment and faecal calprotectin levels before inclusion did not predict relapse. Calprotectin levels of at least 180 after 1 year predicted relapse at year 2.

Conclusion This study found that 73% of patients with CD maintained remission (>2 years) when thiopurine therapy was optimized before withdrawal of anti-TNFα. Additional prospective evidence is needed to confirm the findings.