Are we on our way to change our mode of thinking and treating inflammatory bowel disease patients?

In the last 15 years or so anti-tumor necrosis factor (TNF) treatment has gained popularity, and concepts such striving for endoscopic remission and biomarkers remission (“deep remission”) are becoming upfront issues. Anti-TNF treatment is given for years and safety and economic issues are raised as well. Th e questions when to stop anti-TNF therapy and how to deal with the patient relapses are other hot topics. Molander et al [1] prospectively assessed the relapse rate of infl ammatory bowel disease (IBD) and tried to fi nd predictive factors for relapse aft er discontinuing maintenance therapy with anti-TNF-α agents in patients in “deep remission” for one year (i.e. no clinical symptoms, endoscopic remission, and fecal calprotectin <100 μg/g). In the relapsers, the authors evaluated the response to retreatment with anti-TNF-α agents, initially given at the same dose, and the documented side eff ects. Th is was a prospective multicenter study carried out in 9 Gastroenterology units in Finland. Patients had received anti-TNF-α agents as maintenance therapy for a minimum of one year. Inclusion criteria were innovative in the present study: clinical, endoscopic and laboratory remission, as well as, at least 6 months of steroid-free remission were mandatory. Th us, patients who relapsed aft er anti-TNF cessation belonged to a very strict subgroup, i.e. those in deep remission for 12 months. Relapse aft er discontinuation occurred at a median of 6 (range 2.5-15) months, but, more importantly, at a median of 13 months aft er therapy discontinuation, 67% of patients remained in clinical remission and 85% of them were in endoscopic remission, as well. Furthermore, the response to retreatment with anti-TNF-α during the relapse seemed to be eff ective and well tolerated. All but one patient with relapse achieved clinical remission or response, and 75% of the patients achieved endoscopic remission at the median follow-up period of 12 months, with no important hypersensitivity reactions occurring. No specifi c predictive factor, such as gender, age at diagnosis, disease duration, localization or behavior, smoking, previous surgery or duration of the anti-TNF-α were associated with the relapse when univariate analysis was applied.