Tandem use of Anti-TNF Agents in Patients with IBD who Fail First Line Anti-TNF Therapy: Real Life Lessons from a National Database.

Abstract Background: Inflammatory bowel disease (IBD) is a chronic relapsing and remitting inflammation of the bowel. Biologic therapy is safe and effective in IBD. Anti-TNF agents were the first biologics introduced for treatment of IBD. As more and more anti-TNF agents joined the market, treating physicians started using ant-TNF agents consecutively when the first agent failed. Data for this treatment choice is scanty and therefore we set out to evaluate tandem use of anti-TNF agents in IBD patients.Method: The South African Gastroenterology Society (SAGES) established a national database for all IBD patients commenced on biologic therapy. We used this registry to evaluate the data for all patients who received consecutive anti-TNF agents. Demographic and clinical details as well as treatment outcomes for all patients were documented. Results: Eight-seven (7.6%) of 1150 patients received consecutive anti-TNF agents. The Crohn’s disease (CD) group had 42 (48%) patients and ulcerative colitis (UC) group 45 (52%). Gender distribution was equal with 45 (52%) male and 42 (48%) female patients. All patients failed the first anti-TNF agent over time, but better remission rates were obtained with consecutive anti-TNF agents. Patients treated with adalimumab during any stage of the study, had a higher rate of dose escalation compared to infliximab prior to switching to next anti-TNF agent. Similarly, side effects were also more significant with adalimumab, although few. Few patients required a switch to a third and further biologic agent. All patients remained in clinical remission over 4 years of the study.Conclusion: It is reasonable to try a second anti-TNF agent when the first agent failed in IBD. Switching between different anti-TNF agents maintained clinical remission and avoided surgery and hospitalisation. This is a cost-effective strategy especially in resource constraint settings. Adalimumab is associated with higher rates of dose escalation and worse side-effect profile