Background: When patients with Crohn's disease (CD) are in remission on combination therapy including an anti-tumor necrosis factor (TNF) agent and an immunomodulator (IM), a frequent question is if it is appropriate to stop one of these medications. The aim of this study was to understand gastroenterologists' (GI) perspectives on stopping therapy for patients with CD who are in remission, and to identify differences between European and United States (US) providers.
Methods: Two focus groups, one consisting of European GIs and another with US GIs, were conducted to explore domains to be used for an internet distributed survey. Based on these responses, a questionnaire was developed including quantitative responses and a media component where respondents react to audio recorded during the provider focus groups. US providers were identified from the Crohn's and Colitis Foundation of America (CCFA) professional membership and an established cohort of GIs experienced in internet surveys. The European GIs were identified from a combination of the European Crohn's and Colitis Organisation (ECCO) and French, German and Belgian GI providers.
Results: 309 GIs from the US (182) and Europe (127) completed the questionnaire. Providers from over 30 US states and 16 countries were included. GIs had range of ages from 25–65+. A majority of GIs see 20 or more patients per month and have 10 or more years experience. Almost 30% of US GIs report that more than half of their patients are currently on combination therapy as compared to 10% of European GIs (p<0.05). European GIs were significantly more likely to recommend stopping combination therapy for an average CD patient in remission (44% Europe, 18% US were very likely, p<0.05). 41% of US GIs and 36% of European GIs responded that they would consider stopping combination therapy if there was evidence-based research supporting this strategy. However, a majority of GIs (73% Europe, 52% US) believe that patients at high risk for disease complications should continue on combination therapy. The most compelling reasons to stop therapy were to reduce overall side effects or long term risk of cancers related to the medications. GIs were more likely to stop the IM (75% Europe, 61% US, p<0.05) as opposed to biologic therapy (23% Europe, 29% US). Cancer was the top reason for stopping IMs while cost was the key factor for biologics.
Conclusions: US GIs are more likely than European GIs to have a majority of their CD patients on combination therapy, and European GIs are more likely to de-escalate therapy for patients in remission. If de-escalating, the majority of GIs would stop the IM driven by cancer risk; the main reason to stop a biologic was cost.