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Combination Therapy Use Unchanged in IBD Despite Benefits
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While recent studies have demonstrated its efficacy over anti-TNF monotherapy, use of combination therapy has remained unchanged over time, according to study results.
Charles N. Bernstein, MD, of the University of Manitoba IBD Clinical and Research Center, and colleagues wrote that there are some concerns with combination therapy, including opportunistic infections.
“Multiple epidemiological studies have documented an increased risk of lymphoma among current users of thiopurines and users of anti-TNF, an effect that is amplified when the two drug classes are combined,” they wrote. “Patients and physicians are faced with the task of balancing the benefits of combination therapy with its associated harms.”
Researchers explored the prevalence and predictors of combination therapy compared with anti-TNF monotherapy in IBD by conducting a chart review of patients with IBD treated with anti-TNF in Manitoba from 2005 to 2015.
Off 774 patients, 71% had Crohn’s disease, and 28.3% had ulcerative colitis. Overall, 45.3% of patients received combination therapy with no difference between CD and UC. The proportion of new anti-TNF users who received combination therapy did not change over time.
Patients who had penetrating or perianal CD were more likely to receive combination therapy (56.9% vs. 42.8%; P = .001). Patients with previous IBD-related surgery were less likely to receive combination therapy (36.3% vs. 46.2%; P = .002).
Although risks like infection and malignancy have been given the most attention in combination therapy for IBD, they were not the biggest concerns in actual practice. Researchers found that among patients on anti-TNF monotherapy who had previously been exposed to immunosuppressives, more than 40% discontinued immunosuppressives because of treatment failure and medication intolerance. Researchers wrote that these factors might explain why patients and providers are hesitant to use the same medications as part of a combination therapy.
Bernstein and colleagues wrote that there was a wide variation in the prescribing patterns among physicians, which highlights the struggle in finding the right balance between the benefits and potential harm of combination therapy.
“Despite the expansion of therapeutic choices in IBD, it is likely that anti-TNF will remain the first-line biologic of choice for the near future due to reduced cost of biosimilars and clinical experience,” they wrote. “In light of this, combination anti-TNF immunosuppressive therapy remains a valuable part of the modern IBD toolkit, and its use should continue to be encouraged in moderate to severe CD and UC.” – by Alex Young
Disclosures: Bernstein reports serving on advisory boards for AbbVie, Ferring, Janssen, Pfizer, Shire and Takeda and as a consultant for Mylan Pharmaceuticals. He also reports receiving educational grants from AbbVie, Janssen, Pfizer, Shire and Takeda and being on speaker panels for Ferring, Medtronic, Shire and Takeda. Please see the full study for all other authors’ relevant financial disclosures.
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