De-Escalation of Medical Therapy in Crohn’s Disease
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Disclaimer
This algorithm shows the results of an independent BRIDGe research project, and is not intended nor recommended as a substitute for medical advice or treatment. Always seek the advice of a physician or other qualified health care professional regarding any medical questions or conditions.
Definitions used for the analysis and algorithm
- Deep remission was defined as clinical remission plus normalisation of inflammatory biomarkers for a minimum of 6 months while on immunomodulator or anti‐TNF monotherapy or combination therapy
- Age - Young patients were defined as age 16‐24 years, older as 25‐64 years and elderly as ≥65 years.
- Phenotype - Complicated Crohn’s Disease was defined as extensive involvement (>15 cm), history of prior resections(s), fibrostenotic, penetrating, and/or perianal disease (active or previous fissure, fistula or anal stricture); uncomplicated Crohn’s Disease was defined as the absence of complicated disease.
Methods to create the BRIDGe De-Escalation of Medical Therapy in Crohn’s Disease Algorithm
Deep remission is a treatment goal for patients with Crohn's disease, after which de‐escalation of medical therapy may be considered. However, applicability of available study data to real‐world clinical practice can be challenging. We evaluated the appropriateness of de‐escalating immunomodulator or anti-TNF therapy in Crohn's disease patients in deep remission. We applied a modified Delphi panel approach, which is an iterative, evidence-based process that combines the best available scientific data with the collective judgment of IBD specialists. A comprehensive, structured literature review was conducted on the topic of de-escalation of medical therapies, including anti-TNF agents and immunomodulators, in patients with Crohn’s disease. This review was presented to a panel comprising the Building Research in Inflammatory Bowel Disease Globally (BRIDGe) group and three additional IBD experts. Subsequently, the appropriateness, or inappropriateness, of de‐escalation of medical therapy in Crohn’s disease patients in deep remission for at least 6 months was considered in 240 scenarios across five chapters of different patient scenarios, namely - on combination therapy and stopping anti-TNF, on combination therapy and stopping immunomodulator, on combination therapy and dose reduction immunomodulator, stopping anti-TNF monotherapy, and stopping immunomodulator monotherapy. Appropriateness was rated on a scale of 1‐9, such that interventions rated 1‐3 were considered inappropriate, 4‐5 were uncertain and 7‐9 were appropriate. De‐escalation was rated appropriate in 32/240 scenarios (13.3%), inappropriate in 59/240 scenarios (24.6%), and uncertain in 149/240 scenarios (62.1%). From the results of this analysis a web-based algorithm was then developed that produces a recommendation regarding whether to de-escalate medical therapy or not in specific clinical scenarios relevant to a particular patient.
About the BRIDGe group
BRIDGe was formed in 2006 and is composed of a group of gastroenterologists who are all experts in IBD-patient care and focused on patient-centered clinical IBD research.