Use of second Anti-Tumour Necrosis Factor Agent in Inflammatory Bowel Disease When First Agent Failed: A South African Retrospective Study

Background: Inflammatory bowel disease is a chronic relapsing and remitting inflammation of the bowel. Tumour necrosis factor α antagonists are safe and effective in the treatment of inflammatory bowel disease. Indications and outcomes with consecutive anti-tumour necrosis factor agents, although often used, are not clear. Since data for this treatment choice is scarce, we set out to evaluate the use of consecutive anti-tumour necrosis factor agents in patients with inflammatory bowel disease. Method: A national registry established by The South African Gastroenterology Society was used for retrospective data extraction in patients with consecutive anti-tumour necrosis factor agent use. Demographic, clinical details, treatment outcomes and adverse events were documented. Results: Eight-six (7.5%) of 1150 patients received consecutive tumour necrosis factor-antagonists. There were 41 (48%) patients with Crohn’s disease and 45 (52%) with ulcerative colitis. Gender distribution was equal with 45 (52%) male and 41 (48%) female patients. Patients failed the first anti-tumour necrosis factor agent over 30 months, but remission rates improved with second agent. Immunomodulator therapy had no effect of anti-tumour necrosis agent discontinuation rates. Adalimumab treatment had higher rate of dose escalation/switching as well as adverse events compared to infliximab. Most patients remained in clinical remission except a few with CD who required surgery. Conclusion: Using a second anti-tumour necrosis factor agent when the first agent failed is often necessary in inflammatory bowel disease. Although cost-effective, this strategy lacks clarity. Patient selection is crucial and therapeutic drug monitoring should be central in that decision. Adalimumab is associated with higher rates of dose escalation and a worse side-effect profile. Patients with UC switched earlier compared to CD. First Agent Failed: South African Retrospective Study. persistence was longer at 39 months for CD compared to only 13 months for UC. They further noted that males with CD had longer treatment persistence than females but showed no gender difference in UC regarding persistence of treatment. study showed no gender predominance with respect to length of treatment or withdrawal of treatment for either UC or CD.