Optimising IBD patient selection for de-escalation of anti-TNF therapy to immunomodulator maintenance.

OBJECTIVE: Inflammatory bowel disease (IBD) is increasingly managed with the use of biologic therapies. National guidelines (National Institute for Health and Care Excellence (NICE)) suggest considering cessation after 1 year of therapy but lack detailed criteria for this. We aimed to describe clinical outcomes from the introduction of a biologic review panel (BRP) to implement modified criteria for cessation of antitumour necrosis factor (anti-TNF) therapy and step down to single-agent immunomodulator. DESIGN: Retrospective review of patient outcomes following BRP implementation. PATIENTS: All patients on biologic therapy discussed in the BRP within a 5-year period. SETTING: Single IBD network covering three hospital sites. INTERVENTIONS: Modified criteria for biologic cessation were based on published evidence; they excluded individuals with no suitable maintenance immunomodulator, previous surgery or evidence of active disease, additional indications for anti-TNF therapy and previous relapse on biologic cessation. All patients with IBD on a biologic were discussed at the BRP. MAIN OUTCOME MEASURES: Relapse following IBD cessation and relative cost of BRP. RESULTS: 136 patients with IBD were reviewed, with 45 patients meeting the NICE guideline criteria for cessation. The BRP and modified criteria affected decision to withdraw therapy in 38% of these. Therapy was withdrawn in 27 patients, with a 20% 24-month relapse rate. Younger age at cessation was significantly associated with relapse (p=0.01). CONCLUSION: The BRP approach has proved a safe and effective means of decision making in stopping biologic therapy. Future work to inform exclusion criteria is required.

Implementing a self-management strategy in inflammatory bowel disease (IBD): patient perceptions, clinical outcomes and the impact on service.

INTRODUCTION: Patient self-management and its service integration is not a new concept but it may be a key component in the long-term sustainability of inflammatory bowel disease (IBD) service provision, when considering growing disease prevalence and limited resources. METHODS: The IBD team at the Royal Alexandra and Vale of Leven Hospitals in the Clyde Valley region developed a self-management tool, called the 'flare card'. Patients were asked to complete a questionnaire which reflected their opinion on its viability as a self-management intervention. In addition, its utility in terms of service use over a 10-month period in 2016 was compared with a similar cohort of patients over 10 months in 2015. RESULTS: Patients overall felt that the 'flare card' was a viable self-management tool. Positive feedback identified that the intervention could help them aid control over their IBD, improve medication adherence, reduce symptoms and reflected a feeling of patient-centred IBD care. The comparison between 2015 and 2016 service use revealed a significant reduction in IBD and non-IBD service usage, Steroid prescribing and unscheduled IBD care in the flare card supported cohort. CONCLUSIONS: IBD services must continue to adapt to changes within the National Health Service bearing in mind long-term sustainability and continued care provision. The 'flare card' goes further in an attempt to optimise Crohn's disease and ulcerative colitis management by harmonising clinician evaluation and patient's self-initiation of therapy and investigation.