J Pediatr Gastroenterol Nutr. 2021 Jul 1;73(1):54-60.doi: 10.1097/MPG.0000000000003098.

Joseph Meredith ^1 2, Paul Henderson ^1 2, David C Wilson ^1 2, Johan Van Limbergen ³, Eytan Wine ⁴, Richard K Russell ^1 2

Author information

• ¹Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children.
• ²Child Life and Health, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, United Kingdom.
• ³Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands.
• ⁴Edmonton Pediatric IBD Clinic (EPIC), Department of Pediatrics, University of Alberta, Edmonton, Canada.

Abstract

Objectives: To assess current practices around the use of combination immunosuppression in paediatric inflammatory bowel disease (PIBD) with a focus on the subsequent withdrawal process.

Methods: A web-based, 43-question survey.

Results: Surveys were completed by 70 paediatric gastroenterologists (PGs) from 27 nations across Europe, North America, Oceania and Asia from 62 centres covering approximately 15,000 PIBD patients (median of 200 patients [interquartile range (IQR) 130-300] per centre). Routine use of co-immunosuppression was significantly higher with infliximab (IFX) versus adalimumab (ADL) ([61/70, 87.1%] compared with [23/70, 32.9%]; P < 0.01). Thiopurines (azathioprine [AZA] or 6-mercaptopurine) were the preferred option overall for co-immunosuppression. They were favoured with either IFX or ADL (76% and 77%, respectively) and in both ulcerative colitis (UC) and Crohn disease (CD) (84% and 69%) compared with methotrexate (MTX).Immunomodulators were the preferred choice as the initial drug to be withdrawn from the combination therapy rather than anti-tumour necrosis factor-alpha (anti-TNFα) therapy (59/67, 88% [P < 0.01]). The most common withdrawal time was after 6-12 months, with this decision usually based on clinical assessment rather than a scheduled withdrawal time (51/67, 76% vs 16/67, 24%). Indicators of mucosal healing and therapeutic drug monitoring results tended to be the most important "clinical factors" in the withdrawal decision (P = 0.05).

Conclusion: Most PG's favour initial withdrawal of immunomodulator (usually thiopurines) rather than biologic therapy in the step-down process, usually after 6-12 months based on sustained clinical remission. This survey precedes an in-depth, multicentre study of clinical outcomes of withdrawal of co-immunosuppression in PIBD.