De-escalation of biological treatment in inflammatory bowel disease: A comprehensive review.

INTRODUCTION: Biological therapy is an effective treatment for inflammatory bowel disease (IBD). However, due to cost and safety concerns, after achieving remission, dose de-escalation strategies have been suggested.

AIM: To critically review available data on dose de-escalation of biologics (or other advanced therapies) in IBD. We will focus on studies evaluating de-escalation to standard dosing in patients initially optimised, and also on studies assessing de-escalation from standard dosing.

METHODS: A systematic bibliographic search was performed.

RESULTS: The mean frequency of de-escalation after previous dose intensification (12 studies, 1,474 patients) was 34%. The corresponding frequency of de-escalation from standard dosing (5 studies, 3,842 patients) was 4.2%. The relapse rate of IBD following anti-TNF de-escalation to standard dosing in patients initially dose-escalated (10 studies, 301 patients) was 30%. The corresponding relapse rate following anti-TNF de-escalation from standard dosing (9 studies, 494 patients) was 38%. The risk of relapse was lower for patients in clinical, biologic, and endoscopic/radiologic remission at the time of de-escalation. A role of anti-TNF therapeutic drug monitoring in the decision to dose de-escalate has been demonstrated. In patients relapsing after de-escalation, re-escalation is generally effective. De-escalation is not consistently associated with a better safety profile. The cost-effectiveness of the de-escalation strategy remains uncertain. Finally, there is not enough evidence to recommend dose de-escalation of biologics different from anti-TNFs or small molecules.

CONCLUSIONS: Any consideration for de-escalation of biological therapy in IBD must be tailored, taking into account the risks and consequences of a flare and patients' preferences.