To Örebro University

Introduction: The introduction of biologics has changed the concept of treating IBD and especially CD. TNF-inhibitors have been shown to reduce hospitalization and the need of surgery. Furthermore, the benefi t of TNF-inhibitors seem to be more pronounced in fairly newly diagnosed patients, than in patients that have suffered from CD for many years. However, it is still unknown whether early ”aggressive” treatment with biologics can change the natural course of IBD, including achieving a deep long-term remission and in CD avoiding progression to complicated disease behaviour. The aims of the talk are to discuss different potential treatment strategies with respect to biologics and to examine the evidence for continuing or stopping treatment with biologics.

Methods: Literature search of the topic was performed using Medline/Pubmed and the Cochrane database.

Results: Recent studies suggest that mucosal healing is associated with longstanding remission also in CD. Evidence comes from both epidemiological studies and randomized control trials. In the population based IBSEN study, patients diagnosed with IBD 1990-1994, before the introduction of biologics, were included. Patients with CD achieving mucosal healing after one year, had less infl ammation and need of steroids at follow up. In the follow up of the ”Step-up and Top-down” trial, complete mucosal healing after 2 years of therapy predicted sustained, steroid-free remission through out the 2 years follow up, independently of initial treatment. Preliminary data from the GETAID study, suggest that approximately 40% of patients in remission for at least 6 months on combination therapy with immunomodulator and infl iximab, relapse within 1 year after stopping infl iximab. However, patients in ”deep remission”, i.e. clinical remission in combination with endoscopic remission and normal f-Calprotectin had a much lower risk of relapse.

Conclusion: Studies analyzing if early introduction of biologics can decrease bowel damage and change the disease course are warranted. The question when biologics can be stopped or interrupted with sustained remission is of utmostimportance and needs to be addressed.