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Thématique :
- MICI
Originalité :
Intermédiaire
Solidité :
Intermédiaire
Doit faire évoluer notre pratique :
Immédiatement
 
 
Nom du veilleur :
Professeur Philippe MARTEAU
Coup de coeur :
 
 
Inflammatory Bowel Diseases
  2017/09  
 
  2017 Sep;23(9):1555-1565.  
  doi: 10.1097/MIB.0000000000001183  
 
  Thiopurines Dosed to a Therapeutic 6-Thioguanine Level in Combination with Adalimumab Are More Effective Than Subtherapeutic Thiopurine-based Combination Therapy or Adalimumab Monotherapy During Induction and Maintenance in Patients with Long-standing Cro  
 
  Kariyawasam VC, Ward MG, Blaker PA, Patel KV, Goel R, Sanderson JD, Irving PM  
  https://www.ncbi.nlm.nih.gov/pubmed/28786865  
 
 

Abstract

BACKGROUND:

The benefit of concomitant immunomodulation with adalimumab (ADA) in Crohn's disease is poorly understood. We aimed to compare ADA monotherapy with combination therapy with thiopurines, stratified by thioguanine nucleotides (TGNs).

METHODS:

Retrospective observational study of ADA induction and maintenance. Thiopurines were classified according to TGNs (>235 pmol/8 × 10 red blood cell therapeutic).

RESULTS:

At induction, response was more frequent in combination than ADA monotherapy (83% versus 61%, P = 0.02) and with therapeutic compared with subtherapeutic TGNs (87% versus 70% P = 0.011). Among 280 maintenance semesters in 91 patients, remission was higher with combination than monotherapy (81% versus 60%, P < 0.0001) and therapeutic versus subtherapeutic TGNs (85% versus 58%, P = 0.004). Therapeutic TGN (odds ratio [OR] 4.32, 95% CI, 1.41-13.29, P = 0.01) and albumin (OR 1.09, 95% CI, 1.01-1.18, P = 0.03) were predictors of response to induction. Therapeutic TGN (OR 3.71, 95% CI, 1.87-7.34, P < 0.0001) and ileal disease (OR 0.21, 95% CI, 0.08-0.57, P = 0.002) were predictors of remission semesters. Concomitant immunomodulation at induction was associated with longer time to failure (69 versus 36 months, P = 0.009). Therapeutic TGN at induction (P = 0.03) and male sex (P = 0.026) were associated with time to failure.

CONCLUSIONS:

Combination therapy was superior to ADA monotherapy for induction and during maintenance. This benefit was increased further when thiopurines resulted in therapeutic TGNs. Early use of adequately dosed thiopurines (≥3 months before starting ADA) was associated with improved clinical outcomes.

 

 
Question posée
 
L’adjonction d’un immunosuppresseur et sa posologie modifient-elles l’efficacité de l’adalimumab dans la maladie de Crohn?
 
Question posée
 
Cette étude suggère que oui.
 
Commentaires

La réponse à cette question n’est pas claire dans la littérature et prouver que la monothérapie est aussi efficace que la combothérapie est (comme pour toute étude d’équivalence) beaucoup plus difficile. 

 
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