Anti-Tumor Necrosis Factor Therapies and Cochrane Reviews

A recent article (Inflamm Bowel Dis 2014; 20: 2132-41) reviews the best available evidence on anti-TNF therapies.  This article emerged from a Cochrane collaboration session at Digestive Diseases Week (DDW) in 2013.

Key points:

  • “There is insufficient evidence to recommend ECI (early combined immunosuppression)) for every newly diagnosed patient, although it may be justifiable in some “high-risk” patients.”
  • With Crohn’s disease, combination of infliximab and azathioprine significantly improved remission, steroid-free remission, and mucosal healing rates compared with infliximab alone.
  • “A recent Cochrane review has shown that infliximab, adalimumab, and certolizumab are all effective…The choice of TNF-α antagonist depends on adherence, patient preference, mode of delivery, and cost.
  • Elective switching of TNF-α antagonists: in patients who are doing well, elective switching “may be associated with loss of both tolerance and efficacy.”  “Dose intensification or early treatment termination was observed in 47% of patients who switched to adalimumab after an ongoing response to scheduled maintenance infliximab therapy compared with 16% of patients who remained on infliximab maintenance therapy.” 28% of ADA patients discontinued therapy compared with 2% of IFX patients.
  • When to stop therapy: among patients in deep remission >6 months who stopped, relapse occurred in 43.9% over 1 year.
  • Patients who take thiopurines or biologics (IFX or ADA) have an increased risk of nonmelanoma skin cancer. Odds ratio, compared to controls, as high as 6.75 for combination therapy (>365 days).
  • Lymphoma: the Cochrane review “found no statistically significant difference in the incidence of lymphoma between biologics and control treatment…and data from the TREAT registry also demonstrated no apparent signal for TNF-α antagonist (i.e. infliximab)-related lymphoma or overall malignancy.”
  • There has been incremental risk of Non-Hodgkin’s lymphoma and hepatosplenic T-cell lymphoma with azathioprine (thiopurines).

Related blog posts:

Other articles briefly noted:

Inflamm Bowel Dis 2014; 20: 2142-50. “Approach and management of patients with chronic hepatitis B and hepatitis C during the course of inflammatory bowel disease.”

Inflamm Bowel Dis 2014; 20: 2151-56.  Use of cyclosporin and tacrolimus in inflammatory bowel disease.  Checking hepatitis B surface antigen, surface antibody, and core antibody are recommended at the time of diagnosis of IBD. Algorithm for managing hepatitis B serology is given in Figure 1.


2 thoughts on “Anti-Tumor Necrosis Factor Therapies and Cochrane Reviews

  1. Pingback: Withdrawing Therapy Leads To Relapse, Even if in Deep Remission | gutsandgrowth

  2. Pingback: Stopping Infliximab –What Happens Next? | gutsandgrowth

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