Withdrawal of combination immunotherapy in paediatric inflammatory bowel disease – an international survey of practice

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 (PG) from 27 nations across Europe, North America, Oceania and Asia from 62 centres covering approximately 15,000 PIBD patients (median of 200 patients (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’s 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 Immunomodulators were the preferred choice as the initial drug to be withdrawn from the combination therapy rather than anti-Tumour Necrosis Factor-alpha (anti-TNF) therapy (59/67, 88% [p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% versus 16/67, 24%). Indicators of mucosal healing and therapeutic drug monitoring (TDM) 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.