title: When do we dare to stop biological or immunomodulatory therapy for Crohn's disease? Results of a multidisciplinary European expert panel.
abstract: BACKGROUND
  Safety and economic issues have increasingly raised concerns about the long term use of immunomodulators or biologics as maintenance therapies for Crohn's disease (CD). Despite emerging evidence suggesting that stopping therapy might be an option for low risk patients, criteria identifying target groups for this strategy are missing, and there is a lack of recommendations regarding this question.
  
  
  METHODS
  Multidisciplinary European expert panel (EPACT-II Update) rated the appropriateness of stopping therapy in CD patients in remission. We used the RAND/UCLA Appropriateness Method, and included the following variables: presence of clinical and/or endoscopic remission, CRP level, fecal calprotectin level, prior surgery for CD, and duration of remission (1, 2 or 4 years).
  
  
  RESULTS
  Before considering withdrawing therapy, the prerequisites of a C-reactive protein (CRP) and fecal calprotectin measurement were rated as "appropriate" by the panellists, whereas a radiological evaluation was considered as being of "uncertain" appropriateness. Ileo-colonoscopy was considered appropriate 1 year after surgery or after 4 years in the absence of prior surgery. Stopping azathioprine, 6-mercaptopurine or methotrexate mono-therapy was judged appropriate after 4 years of clinical remission. Withdrawing anti-TNF mono-therapy was judged appropriate after 2 years in case of clinical and endoscopic remission, and after 4 years of clinical remission. In case of combined therapy, anti-TNF withdrawal, while continuing the immunomodulator, was considered appropriate after two years of clinical remission.
  
  
  CONCLUSIONS
  A multidisciplinary European expert panel proposed for the first time treatment stopping rules for patients in clinical and/or endoscopic remission, with normal CRP and fecal calprotectin levels.
authors.affiliation: Healthcare Evaluation Unit, Institute of Social & Preventive Medicine (IUMSP), Lausanne University Hospital, Lausanne, Switzerland. Electronic address: Valerie.Pittet@chuv.ch.
authors.forename: Valerie
authors.initials: V
authors.lastname: Pittet
authors.forename: Florian
authors.initials: F
authors.lastname: Froehlich
authors.forename: Michel H
authors.initials: MH
authors.lastname: Maillard
authors.forename: Christian
authors.initials: C
authors.lastname: Mottet
authors.forename: Jean-Jacques
authors.initials: JJ
authors.lastname: Gonvers
authors.forename: Christian
authors.initials: C
authors.lastname: Felley
authors.forename: John-Paul
authors.initials: JP
authors.lastname: Vader
authors.forename: Bernard
authors.initials: B
authors.lastname: Burnand
authors.forename: Pierre
authors.initials: P
authors.lastname: Michetti
authors.forename: Alain
authors.initials: A
authors.lastname: Schoepfer
mesh_terms: D002097:C-Reactive Protein / Q000378:metabolism; D003113:Colonoscopy; D003424:Crohn Disease / Q000097:blood / Q000188:drug therapy* / Q000473:pathology; D005243:Feces / Q000737:chemistry; D006801:Humans; D056747:Immunomodulation; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D039841:Leukocyte L1 Antigen Complex / Q000032:analysis; D012074:Remission Induction; D013997:Time Factors; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors; D028761:Withholding Treatment
chemical_list: D007166:Immunosuppressive Agents; D039841:Leukocyte L1 Antigen Complex; D014409:Tumor Necrosis Factor-alpha; D002097:C-Reactive Protein
keywords: Anti-TNF drugs; Azathioprine; Crohn's disease; Treatment cessation; Treatment stopping rules