Retrospective Study
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Pharmacol Ther. Feb 6, 2018; 9(1): 8-13
Published online Feb 6, 2018. doi: 10.4292/wjgpt.v9.i1.8
Declining use of combination infliximab and immunomodulator for inflammatory bowel disease in the community setting
Joshua C Berkowitz, Joanna Stein-Fishbein, Sundas Khan, Richard Furie, Keith S Sultan
Joshua C Berkowitz, Sundas Khan, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY 11030, United States
Joanna Stein-Fishbein, Feinstein Institute for Medical Research, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY 11030, United States
Richard Furie, Department of Medicine, Division of Rheumatology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY 11030, United States
Keith S Sultan, Department of Medicine, Division of Gastroenterology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY 11030, United States
Author contributions: Berkowitz JC and Sultan KS designed the study, gathered, analyzed the data and composed the manuscript; Stein-Fishbein J contributed to data analysis and manuscript drafting; Khan S and Furie R contributed to data collection and to the drafting of the manuscript.
Institutional review board statement: This study was approved by the Northwell Health Institutional Review Board.
Conflict-of-interest statement: The authors have no conflicts of interest to report.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Keith S Sultan, MD, Associate Professor, Department of Medicine, Division of Gastroenterology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Dr., Manhasset, NY 11030, United States. ksultan@northwell.edu
Telephone: +1-516-3873990 Fax: +1-516-3873930
Received: March 20, 2017
Peer-review started: March 23, 2017
First decision: May 3, 2017
Revised: August 2, 2017
Accepted: November 9, 2017
Article in press: November 9, 2017
Published online: February 6, 2018
Abstract
AIM

To describe trends of combination therapy (CT) of infliximab (IFX) and immunomodulator (IMM) for inflammatory bowel disease (IBD) in the community setting.

METHODS

A retrospective study was conducted of all IBD patients referred for IFX infusion to our community infusion center between 04/01/01 and 12/31/14. CT was defined as use of IFX with either azathioprine, 6-mercaptopurine, or methotrexate. We analyzed trends of CT usage overall, for Crohn’s disease (CD) and ulcerative colitis (UC), and for the subgroups of induction patients. We also analyzed the trends of CT use in these groups over the study period, and compared the rates of CT use prior to and after publication of the landmark SONIC trial.

RESULTS

Of 258 IBD patients identified during the 12 year study period, 60 (23.3%) received CT, including 35 of 133 (26.3%) induction patients. Based on the Cochran-Armitage trend test, we observed decreasing CT use for IBD patients overall (P < 0.0001) and IBD induction patients, (P = 0.0024). Of 154 CD patients, 37 (24.68%) had CT, including 20 of 77 (26%) induction patients. The Cochran Armitage test showed a trend towards decreasing CT use for CD overall (P < 0.0001) and CD induction, (P = 0.0024). Overall, 43.8% of CD patients received CT pre-SONIC vs 7.4% post-SONIC (P < 0.0001). For CD induction, 40.0% received CT pre-SONIC vs 10.8% post-SONIC (P = 0.0035). Among the 93 patients with UC, 19 (20.4%) received CT. Of 50 induction patients, 14 (28.0%) received CT. The trend test of the 49 patients with a known year of induction again failed to demonstrate any significant trends in the use of CT (P = 0.6).

CONCLUSION

We observed a trend away from CT use in IBD. A disconnect appears to exist between expert opinion and evidence favoring CT with IFX and IMM, and evolving community practice.

Keywords: Crohn’s disease, Ulcerative colitis, Infliximab, Azathioprine, Inflammatory bowel disease

Core tip: In our 13 year experience at a community hospital infusion center, approximately 26% of inflammatory bowel disease patients receiving infliximab infusions received concomitant immunomodulator therapy. This is comparable to rates of combination therapy (CT) at major tertiary referral centers. However, there was a trend of decreased utilization of CT over the study period, even following the publication of SONIC. This suggests a need for further study to define the population with the most favorable risk-benefit ratio from CT, as well as the need for more direct guidelines from major societies.