Pediatric gastroenterologists significantly favor initial withdrawal of an immunomodulator rather than biologic therapy during the step-down process from combination therapy in pediatric inflammatory bowel disease (PIBD), according to a study in the Journal of Pediatric Gastroenterology and Nutrition.

A total of 70 pediatric gastroenterologists completed a 43-question web-based survey, which yielded a response rate of about 50%. Responders were from 27 nations in Europe, North America, Oceania, and Asia, and each of the involved 62 pediatric gastroenterology centers managed a median of 200 (interquartile range, 130-300) patients with PIBD. Among the responders, 45 (64%) had >10 years of clinical experience in pediatric gastroenterology, and 22 (31%) had >20 years of experience.

The survey results showed that significantly more pediatric gastroenterologists used co-immunosuppression with infliximab (IFX) compared with adalimumab (ADL) (61/70, 87% vs 23/70, 33%; P <.01). The rate for prescribing an immunomodulator with IFX was 3-fold higher compared with ADL (57% vs 17%, respectively).

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Responders preferred thiopurines (azathioprine or 6-mercaptopurine) for co-immunosuppression with either IFX or ADL (76% and 77%, respectively), and methotrexate was more frequently preferred in patients with Crohn disease vs those with ulcerative colitis (30% vs 13%, respectively).

Immunomodulators were preferred (59/67; 88%; P <.01) as the initial drug to be withdrawn from combination therapy, and no significant difference was observed regarding strategy according to disease classification or anti-tumor necrosis factor (TNF)-α therapy. The most frequent time to withdraw and change to monotherapy was 6 to 12 months postinitiation, and most pediatric gastroenterologists based this decision on clinical assessment compared with a scheduled timetable (76%, 51/67 vs 24%, 16/67, respectively).

Indicators of mucosal healing and therapeutic drug monitoring results were generally the most important clinical factors in withdrawing (P =.05). Clinical scoring systems such as the Pediatric Ulcerative Colitis Activity Index/Weighted Pediatric Crohn Disease Activity Index and achievement of a specific calprotectin level were of intermediate importance, while indicators of transmural healing were regarded as less important.

The researchers noted that their results are biased towards English-speaking and European centers and that most of the institutions were from nations with a relatively high socioeconomic status, where anti-TNF-α therapies and therapeutic drug monitoring are more accessible. Additionally, 39% of responders relied on database metrics when filling out their questionnaires.

“Wide variation exists in the importance placed on factors such as gender and [Epstein–Barr virus] status in the decision to use co-immunosuppression with anti-TNF-α therapy, and evidence-based guidance is needed here,” the study authors commented. “This survey has informed an in-depth, multicentre study of outcomes of withdrawal from co-immunosuppression in PIBD,” they concluded.

Disclosure: Some of the study authors declared affiliations with pharmaceutical companies. Please see the original reference for a full list of authors’ disclosures.


Meredith J, Henderson P, Wilson DC, et al. Withdrawal of combination immunotherapy in paediatric inflammatory bowel disease—an international survey of practice. J Pediatr Gastroenterol Nutr. 2021;73(1):54-60. doi: 10.1097/MPG.0000000000003098