Maintenance treatment in asymptomatic patients with IBD

Dr John Marshall is a professor and director in the Division of Gastroenterology at McMaster University and editor in chief of the Journal of the Canadian Association of Gastroenterology.

How long should maintenance treatment be used in an asymptomatic patient with inflammatory bowel disease (IBD)? What tests should be performed before treatment discontinuation?

John Marshall, MD, MSc: This is a very common question in clinical practice. Certainly, patients always ask how long they need to be on therapy and those who are doing well are very keen to discontinue therapy because—I think it is understandable—in our patients’ mind they are not really well until they are well and off medication.

I would suggest that there is not really a medical indication to discontinue therapy in a patient doing well. As long as that therapy is affordable to the patient and as long as that patient is tolerating the therapy well, I do not think there is a medical indication to stop therapy. In fact, our preference is to continue therapy indefinitely in patients who have had a good response. Nonetheless, there are often scenarios where at the patient’s request we have to consider stopping therapy and ones where at the peers’ request we are forced to consider stopping therapy.

I think we have learned from some cohort analyses, such as the STORI cohort, that there are subgroups of patients who seem to have a better prognosis off therapy and that reflects the depth of remission. If a patient wants to have that discussion about stopping therapy, we will typically do some investigation, which could include endoscopy or cross-sectional imaging to assess the residual disease burden and measurement of inflammatory markers. If they are in a deep remission, that is, not only their symptoms are under control but also there is no residual evidence of disease activity, this may be a subset at low risk of recurrence in whom we could consider stopping therapy. But I think patients have to understand that there is no guarantee and there is always the risk that if they stop therapy and the disease recurs, the same agent may not be as effective the second time around.