Issue 18

Clinical Question

Does using an immunomodulator with an anti-TNF affect treatment success?

Editor’s Bottom Line

These results support use of combination therapy in patients with Crohn’s disease, but residual confounding by indication in these observational data cannot be excluded.

Reference

Targownik LE, Benchimol EI, Bernstein CN, et al. Upfront Combination Therapy, Compared with Monotherapy, for Patients Not Previously Treated with a Biologic Agent Associates with Reduced Risk of Inflammatory Bowel Disease-related Complications in a Population-based Cohort Study. Clin Gastroenterol Hepatol. 2019;17(9):1788–98.e2; https://doi.org/10.1016/j.cgh.2018.11.003.

Synopsis

To add to the body of real-world evidence documenting the efficacy of combination IBD therapy with an immunomodulator and an anti-tumor necrosis factor (TNF) agent, researchers examined data from 852 individuals with Crohn’s disease (CD) and 303 with ulcerative colitis (UC) who initiated treatment with either anti-TNF monotherapy or combination therapy between 2001 through 2016. The patients were treated at multiple sites in Manitoba and registered in the Manitoba IBD Epidemiology database.

Results showed that there was no significant difference between combination and monotherapy in terms of the efficacy of treatment during the first 90 days, but combination therapy decreased the likelihood of treatment ineffectiveness during the maintenance stage by 38% among CD patients (Adjusted Hazard Ratio [aHR]: 0.62; 95% Confidence Interval [CI], 0.49–0.79). Treatment ineffectiveness was defined as IBD-related hospitalization, intestinal resection, corticosteroid use, or change of anti-TNF agent. In patients with CD, combination therapy was also linked to a significantly longer time to first IBD-related hospitalization.

The authors did not find a statistically significant difference in outcomes among UC patients who received combination or monotherapy (aHR, 0.82; 95% CI, 0.56–1.20).

The choice of anti-TNF agent and immunosuppressant did not affect the likelihood of treatment ineffectiveness.

Details

Study Design: Retrospective population-based
Funding: The study was supported through a grant from the Crohn’s and Colitis Canada Grants in Aid of Research, and the Helmsley Foundation.
Allocation: Not applicable
Setting: Database
Level of Evidence: 2b (Oxford Levels of Evidence)

The summary and conclusion in this issue of E-mentoring in IBD pertains to the manuscript(s) being reviewed, and should be considered in the context of what is already known surrounding the topic and incorporated into practice as deemed appropriate by the individual learner.