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Letter: biologics treatment in Crohn's disease and risk of bowel resection—what about the patients who stop anti‐TNF therapy? Authors’ reply

EDITORS, We thank Ribaldone et al for their letter regarding our cohort study published in AP&T. In our study, we did not observe any statistically significant difference in bowel resection rates between patients stopping TNF inhibitors (TNFi) before 12 months and patients with at least 12 months drug survival. Possible explanations for these results could include more severe disease in the patients with drug survival ≥ 12 months with few therapeutic alternatives or too late an introduction of biologics when complications such as strictures and penetrating disease abrogate the efficacy of TNF inhibition. Ribaldone et al raise an important question whether the use of immunomodulators or systemic corticosteroids after stopping antiTNF could have influenced the risk of surgery. As a response to this we have analyzed the proportion of patients and the number of prescriptions of prednisolone and immunomodulators 1 year before start of TNFi, during the year immediately after start of TNFi, and within the first year of followup. As seen in Table 1, the proportion of patients with prednisolone prescriptions was higher after start of TNFi in patients with drug survival < 12 months. No difference was seen in relation to the prescription of immunomodulators. In addition, we have also analyzed the use of outpatient and inpatient care in the two groups. As expected, there was a greater need for inpatient care in the patients with drug survival < 12 months, which was also reflected in the significantly increased number of hospitalization days in patients failing on biologics before 1 year. There was also an increased use of outpatient care resources in this group. These observations suggest that even though no clear difference was seen in the bowel resection rates, patients with TNFi drug survival < 12 months seem to use more prednisolone and health care resources.