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A.S. Cheifetz, J.D. Feuerstein (eds.), Treatment of Inflammatory
Bowel Disease with Biologics, https://doi.org/10.1007/978-3-319-60276-9_7
Chapter 7
Concomitant Use of Immunosuppressive
Therapy with Tumor Necrosis Factor (TNF)
Antagonists in Inflammatory Bowel Disease
Parambir S. Dulai and Corey A. Siegel
Efficacy
TNF-Antagonists
The rationale for using concomitant immunosuppressive therapy with TNF-
antagonists comes from the impact these agents have on antidrug antibody forma-
tion and drug concentrations, which in turn may influence treatment efficacy and
outcomes [ 1 – 5 ]. Randomized controlled trials (RCTs) and observational data have
supported this hypothesis [ 6 ], but the association between concomitant immunosup-
pressive use and treatment outcomes is less well established.
Comparative effectiveness RCTs have demonstrated that the combination of inf-
liximab and azathioprine is more efficacious than infliximab monotherapy for both
CD and UC [ 7 , 8 ]. The combination of infliximab and methotrexate however has not
been demonstrated to be more efficacious than infliximab monotherapy in CD [ 9 ]
(Table 7.1).
At face value, these data would suggest that when using concomitant immunosup-
pressive therapy, providers should only use azathioprine, but several considerations
need to be made when interpreting these results. First, COMMIT had no minimum
disease activity requirement for entry which resulted in the recruitment of patients
with a much milder disease course. Second, COMMIT used a high-dose steroid induc-
tion regimen in both treatment arms. Given the known treatment benefits of concomi-
tant steroid use and impact of triple induction (steroids + azathioprine + infliximab)
P.S. Dulai
University of California at San Diego, La Jolla, CA, USA
C.A. Siegel (*)
Dartmouth-Hitchcock Inflammatory Bowel Disease Center, Section of Gastroenterology and
Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
e-mail: [email protected]