title: Outcome of elective withdrawal of anti-tumour necrosis factor-α therapy in patients with Crohn's disease in established remission.
abstract: OBJECTIVE
  Outcomes of cessation of anti-TNF therapy for Crohn's disease (CD) in clinical and/or endoscopic remission in routine clinical practice is uncertain. This study aimed to evaluate clinical outcomes and factors associated with relapse in CD patients following formal disease assessment and elective anti-TNF withdrawal.
  
  
  METHODS
  Prospective observational study of CD patients in whom anti-TNF therapy was stopped electively after ≥12months and follow-up of ≥6months. Investigations at assessment prior to cessation included ≥1 of clinical assessment, endoscopic and/or imaging. Relapse was defined as recurrent symptoms of CD requiring medical or surgical therapy.
  
  
  RESULTS
  Eighty-six patients received anti-TNF for a median duration of 23 (12-80) months for severe active luminal (70%), fistulating perianal (25.5%) and other fistulating disease (4.5%). Relapse rates at 90,180 and 365days were 4.7%, 18.6% and 36%, respectively. If anti-TNF dose escalation occurred 6months prior to withdrawal, 88% (7/8) relapsed. Based on multivariate analysis, risk factors for relapse include ileocolonic disease at diagnosis and previous anti-TNF therapy. An elevated faecal calprotectin (FC) is likely to predict relapse (p=0.02), with a PPV of 66.7% at >50μg/g. Of 36 patients who relapsed, 31 were retreated with anti-TNF, with an overall recapture rate of 93%.
  
  
  CONCLUSIONS
  Relapse rates at 1year following elective withdrawal of anti-TNF are 36%, with high retreatment response rate. Predictors of relapse include ileocolonic involvement, previous anti-TNF therapy and raised FC. Endoscopic/radiologic assessment prior to cessation of therapy does not appear to predict those at lower risk of relapse.
authors.affiliation: Gastroenterology and Liver Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S10 2JF, UK Gastroenterology and Liver Unit Royal Hallamshire Hospital Sheffield Teaching Hospitals NHS Foundation Trust Sheffield S10 2JF UK.
authors.forename: A J
authors.initials: AJ
authors.lastname: Brooks
authors.affiliation: Department of Gastroenterology, Hull & East Yorkshire NHS Trust, Castle Hill Hospital, Cottingham, HU16 5JQ, UK Department of Gastroenterology Hull & East Yorkshire NHS Trust Castle Hill Hospital Cottingham HU16 5JQ UK.
authors.forename: S
authors.initials: S
authors.lastname: Sebastian
authors.affiliation: Department of Neuroscience, Faculty of Medicine, Dentistry and Health, The University of Sheffield, Beech Hill Road, Sheffield S10 2RX, UK Department of Neuroscience Faculty of Medicine Dentistry and Health The University of Sheffield Beech Hill Road Sheffield S10 2RX UK.
authors.forename: S S
authors.initials: SS
authors.lastname: Cross
authors.affiliation: Gastroenterology and Liver Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S10 2JF, UK Gastroenterology and Liver Unit Royal Hallamshire Hospital Sheffield Teaching Hospitals NHS Foundation Trust Sheffield S10 2JF UK.
authors.forename: K
authors.initials: K
authors.lastname: Robinson
authors.affiliation: Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Beckett Street, Leeds, West Yorkshire LS9 7TF, UK Department of Gastroenterology Leeds Teaching Hospitals NHS Trust St James's University Hospital Beckett Street, Leeds West Yorkshire LS9 7TF UK.
authors.forename: L
authors.initials: L
authors.lastname: Warren
authors.affiliation: Gastroenterology and Liver Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S10 2JF, UK Gastroenterology and Liver Unit Royal Hallamshire Hospital Sheffield Teaching Hospitals NHS Foundation Trust Sheffield S10 2JF UK.
authors.forename: A
authors.initials: A
authors.lastname: Wright
authors.affiliation: Gastroenterology and Liver Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S10 2JF, UK Gastroenterology and Liver Unit Royal Hallamshire Hospital Sheffield Teaching Hospitals NHS Foundation Trust Sheffield S10 2JF UK.
authors.forename: A M
authors.initials: AM
authors.lastname: Marsh
authors.affiliation: Department of Gastroenterology, Hull & East Yorkshire NHS Trust, Castle Hill Hospital, Cottingham, HU16 5JQ, UK Department of Gastroenterology Hull & East Yorkshire NHS Trust Castle Hill Hospital Cottingham HU16 5JQ UK.
authors.forename: H
authors.initials: H
authors.lastname: Tsai
authors.affiliation: Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Beckett Street, Leeds, West Yorkshire LS9 7TF, UK Department of Gastroenterology Leeds Teaching Hospitals NHS Trust St James's University Hospital Beckett Street, Leeds West Yorkshire LS9 7TF UK.
authors.forename: F
authors.initials: F
authors.lastname: Majeed
authors.affiliation: Gastroenterology and Liver Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S10 2JF, UK Gastroenterology and Liver Unit Royal Hallamshire Hospital Sheffield Teaching Hospitals NHS Foundation Trust Sheffield S10 2JF UK.
authors.forename: M E
authors.initials: ME
authors.lastname: McAlindon
authors.affiliation: Department of Gastroenterology, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, UK Department of Gastroenterology Bradford Royal Infirmary Duckworth Lane Bradford BD9 6RJ UK.
authors.forename: C
authors.initials: C
authors.lastname: Preston
authors.affiliation: Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Beckett Street, Leeds, West Yorkshire LS9 7TF, UK Department of Gastroenterology Leeds Teaching Hospitals NHS Trust St James's University Hospital Beckett Street, Leeds West Yorkshire LS9 7TF UK.
authors.forename: P J
authors.initials: PJ
authors.lastname: Hamlin
authors.affiliation: Gastroenterology and Liver Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S10 2JF, UK Gastroenterology and Liver Unit Royal Hallamshire Hospital Sheffield Teaching Hospitals NHS Foundation Trust Sheffield S10 2JF UK.
authors.forename: A J
authors.initials: AJ
authors.lastname: Lobo
mesh_terms: D000068879:Adalimumab / Q000627:therapeutic use*; D000293:Adolescent; D000328:Adult; D000368:Aged; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use*; D002648:Child; D003106:Colon; D003113:Colonoscopy; D003424:Crohn Disease / Q000000981:diagnostic imaging / Q000188:drug therapy*; D005243:Feces / Q000737:chemistry; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007082:Ileum; D000069285:Infliximab / Q000627:therapeutic use*; D039841:Leukocyte L1 Antigen Complex / Q000032:analysis; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012008:Recurrence; D012074:Remission Induction; D013997:Time Factors; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors; D028761:Withholding Treatment; D055815:Young Adult
chemical_list: D000894:Anti-Inflammatory Agents, Non-Steroidal; D039841:Leukocyte L1 Antigen Complex; D014409:Tumor Necrosis Factor-alpha; D000069285:Infliximab; D000068879:Adalimumab
keywords: Crohn’s disease; anti-TNF therapy; immunosuppression; treatment withdrawal