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St-Pierre J, Shafrir A, Rubin DT. Interrupting inflammatory bowel disease therapy: why, who, when and how to consider medication holidays. Expert Rev Gastroenterol Hepatol 2024:1-10. [PMID: 39385720 DOI: 10.1080/17474124.2024.2412048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Revised: 08/28/2024] [Accepted: 09/30/2024] [Indexed: 10/12/2024]
Abstract
INTRODUCTION Medication holidays in inflammatory bowel disease (IBD) offer a potential means to balance disease management, costs, and quality of life. This concept is increasingly relevant in light of the chronic nature of IBD, the cumulative side effects associated with long-term pharmacotherapy, and the evolving treatment landscape that now includes a large armamentarium of effective induction, maintenance, and rescue therapies paired with disease monitoring tools that enable early intervention. AREAS COVERED This review critically examines the rationale, implementation, and risks of medication holidays in IBD. Recent evidence is reviewed to help guide the risks of relapse involved with cessation of therapy. The selection criteria for patients, the necessary monitoring protocols, and strategies for managing potential relapses are outlined. EXPERT OPINION Despite the potential benefits, medication holidays in IBD involve significant risks and require careful patient selection and active management. Current research highlights a need for improved predictive models and a deeper understanding of patient-specific outcomes and consequences. The future of medication holidays will depend heavily on advancements in noninvasive monitoring technologies and more personalized approaches to therapy. Ultimately, establishing clearer guidelines for safely conducting medication holidays will be crucial in integrating this strategy into routine clinical practice.
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Affiliation(s)
- Joëlle St-Pierre
- Department of Medicine, University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Asher Shafrir
- Institute of Gastroenterology and Hepatology, Faculty of Medicine, Hadassah Medical Center, Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - David T Rubin
- Department of Medicine, University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
- The MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL, USA
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Louis E, Resche-Rigon M, Laharie D, Satsangi J, Ding N, Siegmund B, D'Haens G, Picon L, Bossuyt P, Vuitton L, Irving P, Viennot S, Lamb CA, Pollok R, Baert F, Nachury M, Fumery M, Gilletta C, Almer S, Ben-Horin S, Bouhnik Y, Colombel JF, Hertervig E. Withdrawal of infliximab or concomitant immunosuppressant therapy in patients with Crohn's disease on combination therapy (SPARE): a multicentre, open-label, randomised controlled trial. Lancet Gastroenterol Hepatol 2023; 8:215-227. [PMID: 36640794 PMCID: PMC9908559 DOI: 10.1016/s2468-1253(22)00385-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 11/04/2022] [Accepted: 11/04/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND The combination of infliximab and immunosuppressant therapy is a standard management strategy for patients with Crohn's disease. Concerns regarding the implications of long-term combination therapy provided the rationale for a formal clinical trial of treatment de-escalation. Our aim was to compare the relapse rate and the time spent in remission over 2 years between patients continuing combination therapy and those stopping infliximab or immunosuppressant therapy. METHODS This multicentre, open-label, randomised controlled trial was performed in 64 hospitals in seven countries in Europe and Australia. Adult patients with Crohn's disease in steroid-free clinical remission for more than 6 months, on combination therapy of infliximab and immunosuppressant therapy for at least 8 months were randomly assigned (1:1:1) to either continue combination therapy (combination group), discontinue infliximab (infliximab withdrawal group), or discontinue immunosuppressant therapy (immunosuppressant withdrawal group). Randomisation was stratified according to disease duration before start of first anti-TNF treatment (≤2 or >2 years), failure of immunosuppressant therapy before start of infliximab, and presence of ulcers at baseline endoscopy. The patient number and group of each stratum were assigned by a central online randomisation website. Treatment was optimised or resumed in case of relapse in all groups. Participants, those assessing outcomes, and those analysing the data were not masked to group assignment. The coprimary endpoints were the relapse rate (superiority analysis) and time in remission over 2 years (non-inferiority analysis, non-inferiority margin 35 days). Analyses were done on an intention-to-treat basis. This study is registered with ClinicalTrials.gov, NCT02177071, and with EU Clinical Trials Register, EUDRACT 2014-002311-41. The trial was completed in April, 2021. FINDINGS Between Nov 2, 2015, and April 24, 2019, 254 patients were screened. Of these, 211 were randomised and 207 were included in the final analysis (n=67 in the combination group, n=71 in the infliximab withdrawal group, and n=69 in the immunosuppressant withdrawal group). 39 patients had a relapse (eight [12%] of 67 in the combination group, 25 [35%] of 71 in the infliximab withdrawal group, six [9%] of 69 in the immunosuppressant withdrawal group). 2-year relapse rates were 14% (95% CI 4-23) in the combination group, 36% (24-47) in the infliximab withdrawal group, and 10% (2-18) in the immunosuppressant withdrawal group (hazard ratio [HR] 3·45 [95% CI 1·56-7·69], p=0·003, for infliximab withdrawal vs combination, and 4·76 [1·92-11·11], p=0·0004, for infliximab withdrawal vs immunosuppressant withdrawal). Of 28 patients who had a relapse and were retreated or optimised according to protocol, remission was achieved in 25 patients (one of two in the combination group, 22 of 23 in the infliximab withdrawal group, and two of three in the immunosuppressant withdrawal group). The mean time spent in remission over 2 years was 698 days (95% CI 668-727) in the combination group, 684 days (651-717) in the infliximab withdrawal group, and 706 days (682-730) in the immunosuppressant withdrawal group. The difference in restricted mean survival time in remission was -14 days (95% CI -56 to 27) between the infliximab withdrawal group and the combination group and -22 days (-62 to 16) between the infliximab withdrawal group and the immunosuppressant withdrawal group. The 95% CIs contained the non-inferiority threshold (-35 days). We recorded 31 serious adverse events, in 20 patients, with no difference in frequency between groups. The most frequent serious adverse events were infections (four in the combination group, two in the infliximab withdrawal group, and one in the immunosuppressant withdrawal group) and Crohn's disease exacerbation (three in the combination group, four in the infliximab withdrawal group, and one in the immunosuppressant withdrawal group). No death nor malignancy was recorded. INTERPRETATION In patients with Crohn's disease in sustained steroid-free remission under combination therapy with infliximab and immunosuppressant therapy, withdrawal of infliximab should only be considered after careful assessment of risks and benefits for each patient, whereas withdrawal of immunosuppressant therapy could generally represent a preferable strategy when considering treatment de-escalation. FUNDING European Union's Horizon 2020.
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Affiliation(s)
- Edouard Louis
- Department of Gastroenterology, University Hospital CHU of Liège, Liège, Belgium.
| | - Matthieu Resche-Rigon
- Université de Paris, ECSTRRA - CRESS UMR1153, INSERM and SBIM, AP-HP, Hôpital Saint-Louis, Paris, France
| | - David Laharie
- Service d'Hépato-gastroentérologie et oncologie digestive CHU de Bordeaux, Hôpital Haut-Lévêque- Université de Bordeaux, Bordeaux, France
| | - Jack Satsangi
- Translational Gastroenterology Unit, Nuffield Department of Medicine, John Radcliffe Hospital, Oxford, UK
| | - Nik Ding
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia; Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Britta Siegmund
- Medical Department, Division of Gastroenterology, Infectious Diseases and Rheumatology, Charité - Universitätsmedizin Berlin, Berlin, Germany; Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Geert D'Haens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam, Netherlands
| | - Laurence Picon
- Hépato-Gastro-Onco-Entérologie, Hôpital Trousseau, Tours, France
| | - Peter Bossuyt
- Imelda GI Clinical Research Center, Imelda General Hospital, Bonheiden, Belgium
| | - Lucine Vuitton
- Department of Gastroenterology, Besançon Univeristy Hospital, Besançon, France; UMR 1098, Franche-Comté University, Besançon, France
| | - Peter Irving
- IBD Unit, Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK; School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Stephanie Viennot
- Department of Gastroenterology, University Hospital of Caen, Caen, France
| | - Christopher A Lamb
- Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK; Department of Gastroenterology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Richard Pollok
- Gastroenterology, St Georges University Hospital, London, UK
| | | | - Maria Nachury
- U1286 - INFINITE - Institute for Translational Research in Inflammation, University of Lille, Inserm, CHU Lille, Lille, France
| | - Mathurin Fumery
- Department of Gastroenterology, University Hospital of Amiens, Amiens, France; Peritox, University of Picardie, Amiens, France
| | - Cyrielle Gilletta
- Department of Gastroenterology and Pancreatology, University Hospital of Toulouse Rangueil, Toulouse, France
| | - Sven Almer
- IBD-unit, Division of Gastroenterology, Karolinska University hospital, Stockholm, Sweden
| | - Shomron Ben-Horin
- Department of Gastroenterology, Sheba Medical Center, Tel-Aviv University, Israel
| | - Yoram Bouhnik
- Department of Gastroenterology, Beaujon Hospital, APHP, Paris Cité University, Clichy, France
| | - Jean-Frederic Colombel
- Department of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Erik Hertervig
- Department of Gastroenterology, Skåne University Hospital, Lund, Sweden
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Bashir NS, Hughes A, Ungar WJ. Infliximab Pricing in International Economic Evaluations in Inflammatory Bowel Disease to Inform Biologic and Biosimilar Access Policies: A Systematic Review. MDM Policy Pract 2023; 8:23814683231156433. [PMID: 36860664 PMCID: PMC9969457 DOI: 10.1177/23814683231156433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 01/17/2023] [Indexed: 03/03/2023] Open
Abstract
Background. Policies mandating the use of lower cost biosimilars in patients with inflammatory bowel disease (IBD) have created concerns for patients who prefer their original biologic. Purpose. To inform the cost-effectiveness of biosimilar infliximab treatment in IBD by systematically reviewing the effect of infliximab price variation on cost-effectiveness for jurisdictional decision making. Data Sources. MEDLINE, Embase, Healthstar, Allied and Complementary Medicine, Joanna Briggs Institute EBP Database, International Pharmaceutical Abstracts, Health and Psychosocial Instruments, Mental Measurements Yearbook citation databases, PEDE, CEA registry, HTA agencies. Study Selection. Economic evaluations of infliximab for adult or pediatric Crohn's disease and/or ulcerative colitis published from 1998 through 2019 in which drug price was varied in sensitivity analysis were included. Data Extraction. Study characteristics, main findings, and results of drug price sensitivity analyses were extracted. Studies were critically appraised. The cost-effective price of infliximab was determined based on the stated willingness-to-pay (WTP) thresholds for each jurisdiction. Data Synthesis. Infliximab price was examined in sensitivity analysis in 31 studies. Infliximab showed favorable cost-effectiveness at a price ranging from CAD $66 to $1,260 per vial, depending on jurisdiction. A total of 18 studies (58%) demonstrated cost-effectiveness ratios above the jurisdictional WTP threshold. Limitations. Drug prices were not always reported separately, WTP thresholds varied, and funding sources were not consistently reported. Conclusion. Despite the high cost of infliximab, few economic evaluations examined price variation, limiting the ability to infer the effects of biosimilar introduction. Alternative pricing strategies and access to treatment could be considered to enable IBD patients to maintain access to their current medications. Highlights In an effort to reduce public drug expenditures, Canadian and other jurisdictional drug plans have mandated the use of lower cost, but similarly effective, biosimilars in patients with newly diagnosed inflammatory bowel disease or require a nonmedical switch for established patients. This switch has created concerns for patients and clinicians who want to maintain the ability to make treatment decisions and remain with the original biologic.It is customary for economic evaluations to assess the robustness of results to variations in high-cost items such as medications. In the absence of economic evaluations of biosimilars, examining biologic drug price in sensitivity analysis provides insight into the cost-effectiveness of biosimilar alternatives. A total of 31 economic evaluations of infliximab for the treatment of inflammatory bowel disease varied the infliximab price in sensitivity analysis.The infliximab price deemed to be cost-effective within each study ranged from CAD $66 to CAD $1,260 per 100-mg vial. A total of 18 studies (58%) demonstrated an incremental cost-effectiveness ratio above the jurisdictional willingness-to-pay threshold. If policy decisions are based on price, then originator manufacturers could consider reducing the price or negotiating alternative pricing models to enable patients with inflammatory bowel disease to remain on their current medications.
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Affiliation(s)
- Naazish S. Bashir
- Program of Child Health Evaluative Sciences,
The Hospital for Sick Children Research Institute, Toronto, ON, Canada
| | - Avery Hughes
- Institute of Health Policy, Management and
Evaluation, the University of Toronto, Toronto, ON, Canada
| | - Wendy J. Ungar
- Wendy J. Ungar, Program of Child Health
Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for
Research and Learning, 686 Bay Street, 11th Floor, Toronto, ON M5G 0A4, USA;
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Syal G, Melmed GY, Almario CV, Spiegel BMR. Azathioprine Withdrawal Is Cost-Effective in Patients with Crohn's Disease in Remission on Infliximab and Azathioprine. Dig Dis Sci 2023; 68:404-413. [PMID: 36512266 DOI: 10.1007/s10620-022-07789-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 12/05/2022] [Indexed: 02/09/2023]
Abstract
BACKGROUND In Crohn's disease, combination therapy with infliximab and azathioprine is more effective than either drug alone but is associated with a higher risk of therapy-related complications. Though therapy de-escalation can reduce risks and save costs, it is associated with a risk of Crohn's disease relapse. AIMS We aimed to study the cost-effectiveness of de-escalation strategies in Crohn's disease patients in remission on infliximab and azathioprine. METHODS We constructed a decision tree with Markov models for continuation of infliximab and azathioprine, discontinuation of azathioprine followed by its re-introduction in case of relapse, discontinuation of azathioprine followed by infliximab dose intensification without azathioprine reintroduction in case of relapse and discontinuation of infliximab. Third-party payers' perspective with a willingness-to-pay threshold of $100,000/quality-adjusted life years was used. Markov cycle length was 3 months, and the study period was 5 years. A 35-year-old patient with Crohn's disease in clinical remission on azathioprine 150 mg daily and infliximab 5 mg/kg every 8 weeks was used for base-case analysis. RESULTS Azathioprine withdrawal followed by its reintroduction upon relapse was the dominant strategy as it was the most effective and least expensive approach on base-case analysis. It was also cost-effective in 99.3% of Monte Carlo trial simulations. AZA withdrawal without IFX dose intensification upon relapse was the least effective and the most expensive strategy. CONCLUSION Azathioprine withdrawal is the most effective and least costly de-escalation strategy in CD patients in remission on combination therapy if AZA re-introduction is performed upon CD relapse.
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Affiliation(s)
- Gaurav Syal
- Division of Gastroenterology, University of California at San Diego, 9452 S Medical Ctr Dr, La Jolla, San Diego, CA, 92037, USA.
| | - Gil Y Melmed
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, 8730 Alden Drive, Second Floor East, Los Angeles, CA, 90048, USA
| | - Christopher V Almario
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Pacific Theaters Building, Suite 800, 116 N. Robertson Blvd., Los Angeles, CA, 90048, USA
| | - Brennan M R Spiegel
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Pacific Theaters Building, Suite 800, 116 N. Robertson Blvd., Los Angeles, CA, 90048, USA
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Efficacy of switching from infliximab to golimumab in patients with ulcerative colitis in deep remission. Acta Gastroenterol Belg 2021; 84:423-428. [PMID: 34599566 DOI: 10.51821/84.3.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND-AIM Intravenously administered biologicals are associated with a huge pressure to Infusion Units and increased cost. We aimed to assess the impact of switching infliximab to golimumab in ulcerative colitis (UC) patients in deep remission. Patients and method: In a prospective, single-centre pilot study UC patients on infliximab mono-therapy for = 2 years, whowere in deep remission, consented to switch to golimumab and were followed for 1 year with clinical assessment, serum and faecal biomarkers, work productivity, satisfaction with treatment and quality of life parameters. Endoscopic remission was assessed by colonoscopy at 1 year. Patients fulfilling the same inclusion criteria, who did not consent to switch to golimumab and continued to receive infliximab mono-therapy, for the same period, served as controls. PATIENTS AND METHODS In a prospective, single-centre pilot study UC patients on infliximab mono-therapy for ≥ 2 years, who were in deep remission, consented to switch to golimumab and were followed for 1 year with clinical assessment, serum and faecal biomarkers, work productivity, satisfaction with treatment and quality of life parameters. Endoscopic remission was assessed by colonoscopy at 1 year. Patients fulfilling the same inclusion criteria, who did not consent to switch to golimumab and continued to receive infliximab mono-therapy, for the same period, served as controls. RESULTS Between October 2015 and October 2017, 20 patients were recruited; however one patient stopped therapy because of pregnancy. All 19 patients who were switched to golimumab were still in clinical, biomarker and endoscopic remission at 1 year and maintained excellent quality of life without any complications. In the control group, 18 of 19 patients were also in deep remission, since only one patient had a flare which was managed with IFX dose intensification. During a median 3 years extension treatment with golimumab only 2 patients experienced a flare of colitis. CONCLUSIONS This pilot study indicates that switching from in-fliximab to golimumab in UC patients in deep remission does not compromise treatment effectiveness or the course of disease; golimumab offers a valid alternative to intravenous infliximab infusions during the COVID-19 pandemic.
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Mahmoud R, van Lieshout C, Frederix GWJ, Jharap B, Oldenburg B. Continuation of Anti-TNF in Patients With Ulcerative Colitis in Remission Is Not Cost-effective Compared With Treatment Withdrawal: A Markov Model. J Crohns Colitis 2021; 15:709-718. [PMID: 33125060 DOI: 10.1093/ecco-jcc/jjaa219] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Anti-tumour necrosis factor alpha [anti-TNF] treatment accounts for 31% of health care expenditures associated with ulcerative colitis [UC]. Withdrawal of anti-TNF in patients with UC in remission may decrease side effects and infections, while promoting cost containment. Approximately 36% of patients relapse within 12-24 months of anti-TNF withdrawal, but reintroduction of treatment is successful in 80% of patients. We aimed to evaluate the cost-effectiveness of continuation versus withdrawal of anti-TNF in patients with UC in remission. METHODS We developed a Markov model comparing cost-effectiveness of anti-TNF continuation versus withdrawal, from a health care provider perspective. Transition probabilities were calculated from literature, or estimated by an expert panel of 11 gastroenterologists. Deterministic and probabilistic sensitivity analyses were performed to account for assumptions and uncertainty. The cost-effectiveness threshold was set at an incremental cost-effectiveness ratio of €80,000 per quality-adjusted life-year [QALY]. RESULTS At 5 years, anti-TNF withdrawal was less costly [-€10,781 per patient], but also slightly less effective [-0.04 QALY per patient] than continued treatment. Continuation of anti-TNF compared with withdrawal costs €300,390/QALY, exceeding the cost-effectiveness threshold. Continued therapy would become cost-effective if the relapse rate following anti-TNF withdrawal was ≥43% higher, or if adalimumab or infliximab [biosimilar] prices fell below €87/40 mg and €66/100 mg, respectively. CONCLUSIONS Continuation of anti-TNF in UC patients in remission is not cost-effective compared with withdrawal. A stop-and-reintroduction strategy is cost-saving but is slightly less effective than continued therapy. This strategy could be improved by identifying patients at increased risk of relapse.
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Affiliation(s)
- Remi Mahmoud
- University Medical Centre Utrecht, Division of Internal Medicine and Dermatology, Department of Gastroenterology and Hepatology, Utrecht, The Netherlands
| | - Chris van Lieshout
- University Medical Centre Utrecht, Julius Centre for Health Sciences and Primary Care, Department of Health Technology Assessment, Utrecht, The Netherlands
| | - Geert W J Frederix
- University Medical Centre Utrecht, Julius Centre for Health Sciences and Primary Care, Department of Health Technology Assessment, Utrecht, The Netherlands
| | - Bindia Jharap
- Meander Medical Centre, Division of Internal Medicine, Department of Gastroenterology and Hepatology, Amersfoort, The Netherlands
| | - Bas Oldenburg
- University Medical Centre Utrecht, Division of Internal Medicine and Dermatology, Department of Gastroenterology and Hepatology, Utrecht, The Netherlands
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Pierre N, Baiwir D, Huynh-Thu VA, Mazzucchelli G, Smargiasso N, De Pauw E, Bouhnik Y, Laharie D, Colombel JF, Meuwis MA, Louis E. Discovery of biomarker candidates associated with the risk of short-term and mid/long-term relapse after infliximab withdrawal in Crohn's patients: a proteomics-based study. Gut 2020; 70:gutjnl-2020-322100. [PMID: 33106355 DOI: 10.1136/gutjnl-2020-322100] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 09/30/2020] [Accepted: 10/02/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE A subset of Crohn's disease (CD) patients experiences mid/long-term remission after infliximab withdrawal. Biomarkers are needed to identify those patients. DESIGN New biomarkers of relapse were searched in the baseline serum of CD patients stopping infliximab when they were under combined therapy (antimetabolite and infliximab) and stable clinical remission (diSconTinuation in CrOhn's disease patients in stable Remission on combined therapy with Immunosuppressors cohort, n=102). From shotgun proteomics experiment (discovery step), biomarker candidates were identified and further targeted by selected reaction monitoring (verification step). The dataset was stratified to search for markers of short-term (<6 months) or mid/long-term relapse (>6 months). The risk of relapse and the predicting capacity associated with biomarker candidates were evaluated using univariate Cox model and log-rank statistic, respectively. To test their complementary predicting capacity, biomarker candidates were systematically combined in pairs. RESULTS Distinct biomarker candidates were associated with the risk (HR) of short-term (15 proteins, 2.9
CONCLUSION We identified for the first time circulating biomarker candidates associated with the risk of mid/long-term relapse in CD patients stopping infliximab. We also highlight a sequence of pathophysiological processes leading to relapse, this could help to better understand the disease progression. Our findings may pave the way for a better non-invasive evaluation of the risk of relapse when contemplating antitumour necrosis factor α withdrawal in CD patients.
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Affiliation(s)
- Nicolas Pierre
- Laboratory of Translational Gastroenterology, GIGA-Institute, Liege University, Liege, Belgium
| | | | - Vân Anh Huynh-Thu
- Department of Electrical Engineering and Computer Science, Liege University, Liege, Belgium
| | - Gabriel Mazzucchelli
- Laboratory of Mass Spectrometry, MolSys Research Unit, Liege University, Liege, Belgium
| | - Nicolas Smargiasso
- Laboratory of Mass Spectrometry, MolSys Research Unit, Liege University, Liege, Belgium
| | - Edwin De Pauw
- Laboratory of Mass Spectrometry, MolSys Research Unit, Liege University, Liege, Belgium
| | - Yoram Bouhnik
- Service de Gastroentérologie et Assistance Nutritive, Hôpital Beaujon, Clichy, France
| | - David Laharie
- Service d'Hépato-Gastroentérologie, CHU de Bordeaux, Bordeaux, France
| | - Jean-Frédéric Colombel
- Division of Gastroenterology, Icahn School of Medicine at Mount Sina, New York, New York, USA
| | - Marie-Alice Meuwis
- Laboratory of Translational Gastroenterology, GIGA-Institute, Liege University, Liege, Belgium
- Hepato-Gastroenterology and Digestive Oncology Department, Liege University, Liege, Belgium
| | - Edouard Louis
- Laboratory of Translational Gastroenterology, GIGA-Institute, Liege University, Liege, Belgium
- Hepato-Gastroenterology and Digestive Oncology Department, Liege University, Liege, Belgium
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Pillai N, Lupatsch JE, Dusheiko M, Schwenkglenks M, Maillard M, Sutherland CS, Pittet VEH, Anderegg C, Bauerfeind P, Beglinger C, Begré S, Belli D, Bengoa JM, Biedermann L, Bigler B, Binek J, Blattmann M, Boehm S, Borovicka J, Braegger CP, Brunner N, Bühr P, Burnand B, Burri E, Buyse S, Cremer M, Criblez DH, de Saussure P, Degen L, Delarive J, Doerig C, Dora B, Dorta G, Egger M, Ehmann T, El-Wafa A, Engelmann M, Ezri J, Felley C, Fliegner M, Fournier N, Fraga M, Frei P, Frei R, Fried M, Froehlich F, Funk C, Furlano RI, Gallot-Lavallée S, Geyer M, Girardin M, Golay D, Grandinetti T, Gysi B, Haack H, Haarer J, Helbling B, Hengstler P, Herzog D, Hess C, Heyland K, Hinterleitner T, Hiroz P, Hirschi C, Hruz P, Iwata R, Jost R, Juillerat P, Keller C, Knellwolf C, Knoblauch C, Köhler H, Koller R, Krieger-Grübel C, Kullak-Ublick G, Künzler P, Landolt M, Lange R, Lehmann FS, Macpherson A, Maerten P, Maillard MH, Manser C, Manz M, Marbet U, Marx G, Matter C, Meier R, Mendanova M, Michetti P, Misselwitz B, Morell B, Mosler P, Mottet C, Müller C, Müller P, Müllhaupt B, Münger-Beyeler C, Musso L, Nagy A, Neagu M, Nichita C, Niess J, Nydegger A, Obialo N, Oneta C, Oropesa C, Peter U, Peternac D, Petit LM, Piccoli-Gfeller F, Pilz JB, Pittet V, Raschle N, Rentsch R, Restellini S, Richterich JP, Rihs S, Ritz MA, Roduit J, Rogler D, Rogler G, Rossel JB, Rueger V, Saner G, Sauter B, Sawatzki M, Schäppi M, Scharl M, Scharl S, Schelling M, Schibli S, Schlauri H, Uebelhart SS, Schnegg JF, Schoepfer A, Seibold F, Seirafi M, Semadeni GM, Semela D, Senning A, Sidler M, Sokollik C, Spalinger J, Spangenberger H, Stadler P, Steuerwald M, Straumann A, Straumann-Funk B, Sulz M, Suter A, Thorens J, Tiedemann S, Tutuian R, Vavricka S, Viani F, Vögtlin J, Von Känel R, Vonlaufen A, Vouillamoz D, Vulliamy R, Wermuth J, Werner H, Wiesel P, Wiest R, Wylie T, Zeitz J, Zimmermann D. Evaluating the Cost-Effectiveness of Early Compared with Late or No Biologic Treatment to Manage Crohn's Disease using Real-World Data. J Crohns Colitis 2020; 14:490-500. [PMID: 31630164 DOI: 10.1093/ecco-jcc/jjz169] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS We evaluated the cost-effectiveness of early [≤2 years after diagnosis] compared with late or no biologic initiation [starting biologics >2 years after diagnosis or no biologic use] for adults with Crohn's disease in Switzerland. METHODS We developed a Markov cohort model over the patient's lifetime, from the health system and societal perspectives. Transition probabilities, quality of life, and costs were estimated using real-world data. Propensity score matching was used to ensure comparability between patients in the early [intervention] and late/no [comparator] biologic initiation strategies. The incremental cost-effectiveness ratio [ICER] per quality-adjusted life year [QALY] gained is reported in Swiss francs [CHF]. Sensitivity and scenario analyses were performed. RESULTS Total costs and QALYs were higher for the intervention [CHF384 607; 16.84 QALYs] compared with the comparator [CHF340 800; 16.75 QALYs] strategy, resulting in high ICERs [health system: CHF887 450 per QALY; societal: CHF449 130 per QALY]. In probabilistic sensitivity analysis, assuming a threshold of CHF100 000 per QALY, the probability that the intervention strategy was cost-effective was 0.1 and 0.25 from the health system and societal perspectives, respectively. In addition, ICERs improved when we assumed a 30% reduction in biologic prices [health system: CHF134 502 per QALY; societal: intervention dominant]. CONCLUSIONS Early biologic use was not cost-effective, considering a threshold of CHF100 000 per QALY compared with late/no biologic use. However, early identification of patients likely to need biologics and future drug price reductions through increased availability of biosimilars may improve the cost-effectiveness of an early treatment approach.
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Affiliation(s)
- Nadia Pillai
- Center for Primary Care and Public Health [Unisanté], University of Lausanne, Lausanne, Switzerland
| | - Judith E Lupatsch
- Institute of Pharmaceutical Medicine [ECPM], University of Basel, Basel, Switzerland
| | - Mark Dusheiko
- Center for Primary Care and Public Health [Unisanté], University of Lausanne, Lausanne, Switzerland.,Faculty of Business and Economics [HEC], University of Lausanne, Lausanne, Switzerland
| | | | - Michel Maillard
- Crohn and Colitis Center, Gastroentérologie Beaulieu SA, Lausanne, Switzerland.,Service of Gastroenterology and Hepatology, Lausanne University Hospital, Lausanne, Switzerland
| | - C Simone Sutherland
- Institute of Pharmaceutical Medicine [ECPM], University of Basel, Basel, Switzerland
| | - Valérie E H Pittet
- Center for Primary Care and Public Health [Unisanté], University of Lausanne, Lausanne, Switzerland
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Louis E. Tailoring Biologic or Immunomodulator Treatment Withdrawal in Inflammatory Bowel Disease. Front Med (Lausanne) 2020; 6:302. [PMID: 31970158 PMCID: PMC6960136 DOI: 10.3389/fmed.2019.00302] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 12/02/2019] [Indexed: 01/16/2023] Open
Abstract
There is currently no cure for inflammatory bowel disease. Most recent treatments and treatment strategies allow for healing intestinal lesions and maintaining steroid-free remission in a subset of patients. These patients and their doctors often ask themselves whether the treatment could be withdrawn. Several studies in both Crohn's disease and ulcerative colitis have demonstrated a risk of relapse, which varies between 20 and 50% at 1 year and between 50 and 80% beyond 5 years. These numbers clearly highlight that stopping therapy should not be a systematically proposed strategy in those remitting patients. Nevertheless, they also indicate that a minority of patients may not relapse over mid-term and that those who have relapsed may have benefited from a drug-free period before being treated again for a new cycle of treatment. In this context, it would be good to optimally select patients who can be candidates for a successful treatment withdrawal. The criteria impacting this decision are as follows: the risk of relapse (linked to factors like mucosal healing and biomarkers), the consequence of a potential relapse, the tolerance and potential side effects of therapy, patients' priorities and preferences, and the costs. Integration of these parameters allows for the proposal of a decisional algorithm that may help the patients and doctors to make an appropriate decision for their individual case.
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Affiliation(s)
- Edouard Louis
- Department of Gastroenterology, University and CHU Liège, Liège, Belgium
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