Exit strategies in inflammatory bowel disease: Looking beyond anti-tumor necrosis factors

Abstract

The long-term management of patients with inflammatory bowel disease (IBD) is still a matter of debate, and no clear guidelines have been issued. In clinical practice, gastroenterologists often have to deal with patients in prolonged remission after immunomodulatory or immunosuppressive therapies. When planning an exit strategy for drug withdrawal, the risk of disease relapse must be balanced against the risk of drug-related adverse events and healthcare costs. Furthermore, there is still a dearth of data on the withdrawal of novel biologics, such as the anti-α4β7 integrin antibody (vedolizumab) and anti-IL12/23 antibody (ustekinumab), as well as the small molecule tofacitinib. Models for estimating the risk of disease relapse and the efficacy of retreatment should be evaluated according to the patient's age and IBD phenotype. These models should guide clinicians in programming a temporary drug withdrawal after discussing realistic outcomes with the patient. This would shift the paradigm from an exit strategy to a holiday strategy.

Keywords: Exit strategy; Biologic withdrawal; Drug holiday; Vedolizumab; Ustekinumab; Tofacitinib

Core Tip: Clinicians are still uncertain about whether and when to consider stopping conventional therapies in inflammatory bowel disease (IBD) for fear of disease relapse. Our review aims to shed light on the optimal discontinuation strategies for biologics and the small molecule tofacitinib in IBD.