Discontinuation of therapy in inflammatory bowel disease: Current views

Abstract

The timely introduction and adjustment of the appropriate drug in accordance with previously well-defined treatment goals is the foundation of the approach in the treatment of inflammatory bowel disease (IBD). The therapeutic approach is still evolving in terms of the mechanism of action but also in terms of the possibility of maintaining remission. In patients with achieved long-term remission, the question of de-escalation or discontinuation of therapy arises, considering the possible side effects and economic burden of long-term therapy. For each of the drugs used in IBD (5-aminosalycaltes, immunomodulators, biological drugs, small molecules) there is a risk of relapse. Furthermore, studies show that more than 50% of patients who discontinue therapy will relapse. Based on the findings of large studies and meta-analysis, relapse of disease can be expected in about half of the patients after therapy withdrawal, in case of monotherapy with aminosalicylates, immunomodulators or biological therapy. However, longer relapse-free periods are recorded with withdrawal of medication in patients who had previously been on combination therapies immunomodulators and anti-tumor necrosis factor. It needs to be stressed that randomised clinical trials regarding withdrawal from medications are still lacking. Before making a decision on discontinuation of therapy, it is important to distinguish potential candidates and predictive factors for the possibility of disease relapse. Fecal calprotectin level has currently been identified as the strongest predictive factor for relapse. Several other predictive factors have also been identified, such as: High Crohn's disease activity index or Harvey Bradshaw index, younger age (< 40 years), longer disease duration (> 40 years), smoking, young age of disease onset, steroid use 6-12 months before cessation. An important factor in the decision to withdraw medication is the success of re-treatment with the same or other drugs. The decision to discontinue therapy must be based on individual approach, taking into account the severity, extension, and duration of the disease, the possibility of side adverse effects, the risk of relapse, and patient’s preferences.

Keywords: Inflammatory bowel disease; Therapy discontinuation; Therapy de-escalation; Ulcerative colitis; Crohn’s disease

Core Tip: Tailoring treatment for inflammatory bowel disease (IBD) hinges on timely drug initiation aligned with treatment objectives. While therapy approaches evolve, achieving and sustaining remission prompts discussions on de-escalating or halting treatment, weighed against long-term therapy risks. With each IBD drug category, relapse risks persist post-discontinuation, impacting over 50% of patients. Withdrawal following combination therapies shows prolonged relapse-free periods, yet randomized trials on medication cessation are limited. Identifying relapse predictors and suitable candidates is pivotal. Re-treatment success underpins therapy withdrawal decisions. Individualized assessments, considering disease severity, duration, side effects, relapse risk, and patient preferences all guide prudent discontinuation choices.