Re-Initiation of Anti TNF Agents After a Drug Holiday or Disease Relapse in Inflammatory Bowel Diseases: A Systematic Review
BACKGROUND: Inflammatory bowel disease is a chronic condition that usually requires life-long treatment, with approximately one third of patients relapsing within 1 year after discontinuation of medications. It’s still not clear whether it’s safe and effective to start anti TNF agents after a drug holiday, with some studies showing benefit but others not. Therefore, we conducted a meta-analysis of studies that looked at restarting anti TNF medications after a drug holiday, to discern whether this can lead to clinical response/remission or not.
METHODS: A comprehensive search of several databases including Ovid MEDLINE Epub Ahead of Print, Ovid Medline In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus was performed up to September 15, 2019. Two independent reviewers systematically identified trials that looked at restarting anti TNF drugs after a drug holiday. A meta-analysis was performed using a random effect model to assess the outcomes of clinical remission after re-initiation of anti TNF.
RESULTS: Total of 17 studies with 918 patients retreated with anti TNF medications after a drug holiday (2 studies) or due to disease relapse (15 studies) met our inclusion criteria and were ultimately included in the final analysis. The remission rate of patients retreated with biologics was abstracted from 17 studies. A binary random effects model was used to pool the proportions of remission from all studies. The pooled rate for remission in those patients was 82.2% (76.7%–87.7%), however we found a serious inconsistency among studies with an i2 value of 79.3%. Additionally, although some of the estimates in individual studies do not fall within the confidence internal of the estimates in the other studies, the pooled estimate for remission ranging from 76.7% to 87.7% indicates precision in the results, as both ends of the confidence interval would lead to the same clinical decision of retreating patients after a drug holiday or relapse.
CONCLUSION(S): Our results indicated that restarting anti TNF after a drug holiday or due to disease relapse may lead to clinical response and can be considered in clinical practice.