This potentially widens the scope for the usage of these drugs in Crohn’s disease
This potentially widens the scope for the usage of these drugs in Crohn’s disease. Currently the UK uses less biologic therapy than its European neighbours but the effect of the new guidance remains to be seen. of infliximab in patients with severe active Crohn’s disease (equating to a Crohn’s Disease Activity Index of >300) but not in patients with fistulising disease alone. Despite the large number of studies suggesting more effective ways of using RU43044 infliximab in the interim, some primary care trusts in the UK have interpreted this guidance very strictly and have continued to restrict the use of infliximab to the 2002 guidance and have refused to fund adalimumab at all. == Figure 1. == Summary of the NICE 2002 guidance. Since 2002, we have learnt much about the best ways to use infliximab: the ACCENT 1 trial clearly demonstrated that scheduled treatment was more effective than episodic treatment in maintaining remission1and that antibodies to infliximab were minimised by this approach.2The correct time in the disease natural history to use infliximab has also been addressed by the Step UpTop Down trial and more recently by SONIC. The Step UpTop Down trial compared initiating treatment with infliximab and azathioprine with the traditional model of starting with corticosteroid therapy and moving through immune suppressants to biologic therapy. Patients in this trial were, on average, started on treatment within 2 weeks of diagnosis. After 2 years there was no statistically significant difference in the number of people in clinical remission in the two arms but those in the infliximab arm had required much less steroid therapy and a higher proportion had been in remission at 6 months and 1 year.3However, in this study, there was no assessment of mucosal healing. SONIC addressed a different group of patientsthose who had relapsed after a single course of corticosteroid therapy. Patients were randomised to receive azathioprine, infliximab or both. The trial demonstrated that for both remission and mucosal healing the combination was RU43044 Rabbit Polyclonal to CEBPZ most effective, and monotherapy with infliximab was more effective than azathioprine. These effects were noted out to 1 1 year.4These trials have clearly demonstrated that maintenance therapy with infliximab is effective but there remain many circumstances within the disease natural history where there is no direct trial evidence to guide treatment and drug usage depends on clinical judgement in combination with patient preference. The other major change since 2002 is the launch of adalimumab for the treatment of Crohn’s disease. This is a fully humanised monoclonal antibody to tumour necrosis factor (whereas infliximab is a chimeric antibody) and has the potential advantage of subcutaneous administration. Efficacy for induction of remission was demonstrated in the CLASSIC-1 trial, RU43044 with 160 mg followed by 80 mg 2 weeks later being the optimal dosing regimen.5Fortnightly dosing was demonstrated to maintain remission in the CLASSIC-II study6and then in the CHARM study and its open label extension.7There have been no head to head trials of adalimumab and infliximab but clinical trials suggest that the efficacy of adalimumab is similar to that of infliximab. The new NICE guidance has taken account of the new evidence, and the 2010 guidance (figure 2) suggests a scheduled course of treatment of 1 1 1 year with the most cost effective therapy, after which a full reassessment of disease activity is required, possibly involving endoscopy. This.