title: Appropriate maintenance treatment for Crohn's disease: Results of a multidisciplinary international expert panel - EPACT II.
abstract: BACKGROUND
  Biological therapy has dramatically changed management of Crohn's disease (CD). New data have confirmed the benefit and relative long-term safety of anti-TNFα inhibition as part of a regular scheduled administration programme. The EPACT appropriateness criteria for maintenance treatment after medically-induced remission (MIR) or surgically-induced remission (SIR) of CD thus required updating.
  
  
  METHODS
  A multidisciplinary international expert panel (EPACT II, Geneva, Switzerland) discussed and anonymously rated detailed, explicit clinical indications based on evidence in the literature and personal expertise. Median ratings (on a 9-point scale) were stratified into three assessment categories: appropriate (7-9), uncertain (4-6 and/or disagreement) and inappropriate (1-3). Experts ranked appropriate medication according to their own clinical practice, without any consideration of cost.
  
  
  RESULTS
  Three hundred and ninety-two specific indications for maintenance treatment of CD were rated (200 for MIR and 192 for SIR). Azathioprine, methotrexate and/or anti-TNFα antibodies were considered appropriate in 42 indications, corresponding to 68% of all appropriate interventions (97% of MIR and 39% of SIR). The remaining appropriate interventions consisted of mesalazine and a "wait-and-see" strategy. Factors that influenced the panel's voting were patient characteristics and outcome of previous treatment. Results favour use of anti-TNFα agents after failure of any immunosuppressive therapy, while earlier primary use remains controversial.
  
  
  CONCLUSIONS
  Detailed explicit appropriateness criteria (EPACT) have been updated for maintenance treatment of CD. New expert recommendations for use of the classic immunosuppressors as well as anti-TNFα agents are now freely available online (www.epact.ch). The validity of these criteria should now be tested by prospective evaluation.
authors.affiliation: Department of Gastroenterology & Hepatology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland; Healthcare Evaluation Unit, Institute of Social & Preventive Medicine (IUMSP), Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland.
authors.forename: Pascal
authors.initials: P
authors.lastname: Juillerat
authors.forename: John-Paul
authors.initials: JP
authors.lastname: Vader
authors.forename: Christian
authors.initials: C
authors.lastname: Felley
authors.forename: Valérie
authors.initials: V
authors.lastname: Pittet
authors.forename: Jean-Jacques
authors.initials: JJ
authors.lastname: Gonvers
authors.forename: Christian
authors.initials: C
authors.lastname: Mottet
authors.forename: Willem A
authors.initials: WA
authors.lastname: Bemelman
authors.forename: Marc
authors.initials: M
authors.lastname: Lémann
authors.forename: Tom
authors.initials: T
authors.lastname: Oresland
authors.forename: Pierre
authors.initials: P
authors.lastname: Michetti
authors.forename: Florian
authors.initials: F
authors.lastname: Froehlich