Challenge of treatment de-escalation in inflammatory bowel diseases

Inflammatory bowel diseases (IBDs) encompass chronic conditions predominantly affecting young individuals and necessitate long-term, advanced treatments to manage disease burden and mitigate progressive tissue damage.1 Within this context, the matter of treatment discontinuation in patients who have achieved sustained remission, including those undergoing combination therapy, holds significant importance for both clinicians and patients. The primary considerations for potential treatment de-escalation or cessation include safety concerns, the financial implications of prolonged therapy and patients’ willingness or preference. In Gut, Gisbert et al 2 address this important question and report the results of the EXIT trial, a randomised placebo-controlled trial on 140 patients in clinical remission under anti-tumour necrosis factor (TNF) antibody and immunomodulators who were randomly assigned to either withdraw or maintain the anti-TNF antibody. Four prospective clinical trials have investigated the question of anti-TNF de-escalation in IBD3–6 but two specifically address treatment de-escalation in patients achieving clinical remission while on combination therapy with infliximab (IFX) and an immunomodulator.3 4 The STORI (infliximab diSconTinuation in CrOhn’s disease patients in stable Remission on combined therapy with Immunosuppressors) trial was the first prospective, single-arm study evaluating clinical relapse after IFX withdrawal in patients in corticosteroid-free remission for at least 6 months on combination therapy with an immunomodulator.3 After a median follow-up of 24 months, 45% experienced relapse. Key findings included …