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Hépato-Gastro & Oncologie Digestive

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Optimisation of biotherapy for Crohn’s disease Volume 16, issue 4, juillet-août 2009

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Authors
Service gastroentérologie CHU St Etienne

About half of the patients receiving long term treatment for Crohn’s disease with anti-TNF’s experience loss of response. None of the novel biotherapies (certolizumab, natalizumab, ustekinumab) that have recently been introduced has demonstrated a clear efficacy, and some have even been associated with serious adverse events. It is therefore essential to optimize the use of the two available anti-TNF’s. In luminal Crohn’s disease, in case of failure of the standard 5 mg/kg doses of infliximab, increasing the doses to 10 mg/kg achieves a 90 % clinical response rate. Shortening the interval between injections to 6 weeks could also give good results, but this strategy has never been properly assessed. Association of these 2 strategies may be proposed. Administration of adalimunab as a rescue therapy should be considered only after proper optimization of infliximab and results in a 20 % response rate. If adalimunab was used as first line therapy for luminal Crohn’s disease, shortening the interval between injections to 40 mg/week achieves a 45 % clinical remission rate. Expert opinion should be sought before attempting to increase the doses to 80 mg/week. In fistulizing Crohn’s disease, a dose increase of infliximab achieves a 57 % clinical response rate. rescue therapy with adalimunab should be decided on a case by case basis.