Therapy de‐escalation in paediatric patients with inflammatory bowel disease in remission: Data analysis from the CEDATA registry

TL;DR

This study analyzes how therapy de-escalation is performed in children with inflammatory bowel disease and identifies factors that predict successful de-escalation.

Contribution

The study provides real-world prognostic factors for successful therapy de-escalation in pediatric IBD patients.

Findings

Crohn's disease patients were more often successfully de-escalated than ulcerative colitis patients.

De-escalation to biologic monotherapy was more successful than to immunomodulator monotherapy or stopping both.

UC patients with less severe disease (Paris E1/E2) had more successful de-escalation than those with more extensive disease (E3/E4).

Abstract

There are no standardized criteria about stepping down from combination therapy (immunomodulator and tumor necrosis factor (TNF)‐alpha‐inhibitors) in children with inflammatory bowel disease (IBD) to reduce risk for side effects. Our aim was to describe how de‐escalation has been performed in a large paediatric cohort and to find prognostic factors for therapy de‐escalation without the need for therapy adjustments post‐de‐escalation.

Real‐world data from CEDATA‐GPGE, a German‐Austrian registry for paediatric IBD patients, from 2004 to 2023, were analyzed. Patients not requiring therapy adjustments post‐de‐escalation and patients requiring therapy adjustments after de‐escalation were compared, and prognostic factors were identified.

Two hundred and thirty out of 6248 registered patients received combination therapy for at least 6 months. In 64 patients therapy adjustment was not required after de‐escalation. Crohn's disease (CD) patients, younger patients, and patients with positive modified predictors of poor outcome were significantly more often on combination therapy. Regarding de‐escalation, CD patients were more often successfully de‐escalated than ulcerative colitis (UC) and IBD‐unclassified patients. UC patients with a less severe disease manifestation (Paris classification E1 or E2) were de‐escalated more successfully than those with more extensive disease (E3 or E4). De‐escalation to monotherapy with a biologic led to a more successful de‐escalation than de‐escalation to immunomodulator monotherapy or stopping both biologic and immunomodulator.

De‐escalation is more likely successful in patients with CD, and de‐escalating combination therapy to monotherapy with a TNF‐alpha‐inhibitor is more advantageous.

Combination therapy is recommended for children with inflammatory bowel disease, but no evidence‐based guidelines for therapy de‐escalation in patients in remission exist.The decision of who, what, and when to de‐escalate is one of the most important yet most challenging decisions for both the patient and clinician.

Combination therapy is recommended for children with inflammatory bowel disease, but no evidence‐based guidelines for therapy de‐escalation in patients in remission exist.

The decision of who, what, and when to de‐escalate is one of the most important yet most challenging decisions for both the patient and clinician.

Our study identifies considerable prognostic factors that can help in the decision‐making process.Combination therapy is more likely successful in children with Crohn's Disease, patients that are de‐escalated to monotherapy with a biologic, and ulcerative colitis patients with less severe disease manifestation (Paris classification E1 or E2).

Our study identifies considerable prognostic factors that can help in the decision‐making process.

Combination therapy is more likely successful in children with Crohn's Disease, patients that are de‐escalated to monotherapy with a biologic, and ulcerative colitis patients with less severe disease manifestation (Paris classification E1 or E2).

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