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To Switch Or Not To Switch TNF Agents In Crohn's Disease
Submit responseIt is with great interest that I read the article entitled "Adalimumab Induction Therapy for Crohn Disease Previously Treated with Infliximab: A Randomized Trial" by Sanborn et al. As a rheumatologist the issue of switching between the three available anti-TNF agents(infliximab, adalimimab, and etanercept)versus changing to a T and B cell directed therapy has emerged as a controversial and yet not well studied area.
Several concerns arise in reading this article which in my opinion questions the validity of the study. First, the definition of infliximab failure due to infusion reactions is not clear. Certainly there are severe reactions such as anaphylactic reactions that would warrant discontinuation. However, they also could stop for reactions such as fever greater than 100F, itching, low blood pressure as well as delayed reactions of myalgias, arthralgias and low grade fever. These reactions are minimal and do not contraindicate the use infliximab. It is possible that some of the 21/95 patients that went into remission and were considered intolerant may have benefitted from repeat infliximab infusion. Additionally, in the group of patients with fistulas(14%), there was only a minimal and nonsignificant response to adalimumab(5/25 in placebo and 3/20 in adalimimab groups). This is a group where infliximab initially showed a marked reponse and I was surprised that this did not occur with the high doses of adalimumab used. Due to the substantial cost of these agents subjects may have also been enrolled as a way to avoid expensive medical therapy.
Overall, it appears that anti-TNF monoclonal antibody therapy has much potential in Crohn's disease and proper use of these agents is beneficial. Further investigations including randomized controlled study of these agents would be of great value.
Conflict of Interest:
Dr. Arkfeld has worked as a speaker for abbott