GIS-SUSANTI-TNF-2015 (Anti-TNF Discontinuation )

Study Overview
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Brief Summary
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This study will be a multicentre prospective randomized trial to assess the percentage of patients with IBD who, after stopping anti-TNF treatment, have sustained clinical remission at one year compared to those in which the treatment is continued at stable doses

Detailed Description
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A multicentre prospective randomized trial. Hypothesis: The discontinuation of anti-TNF treatment in inflammatory bowel disease (IBD) patients in clinical remission is associated with an increased risk of recurrence compared with maintaining such treatment. Main objective: To assess the percentage of patients with IBD who, after stopping anti-TNF treatment, have sustained clinical remission at one year compared to those in which the treatment is continued at stable doses Secondary objectives: To compare treatment discontinuation vs. treatment continuation of anti-TNF agents in patients with Crohn´s disease or ulcerative colitis in terms of: remission (relapse-free) time, phenotype changes with both strategies mucosal healing, radiologic healing impact on quality of life and productivity safety to identify relapse predictive factors. To identify relapse predictive factors after anti-TNF drug discontinuation Determining the profile of serum cytokines in patients with both strategies, depending on drug exposure and if maintained clinical remission or relapse. Planned number of subject to be included: 194 The participation of at 50 hospitals in Spain with an inclusion of about 5 patients per hospital is required.. Case report Form was designed on REDCap (a free, secure, web-based application designed to support data capture for research studies).

Official Title
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Anti-TNF Discontinuation in Patients With Inflammatory Bowel Disease: Multicentre, Prospective, Randomized Clinical Trial and Economic Evaluation

Conditions
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Crohn's Disease, Inflammatory Bowel Disease, Ulcerative Colitis

Intervention / Treatment
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* Biological: Anti-TNF: Infliximab (Infusion)
* Drug: Anti-TNF discontinuation: Physiological saline solution
* Biological: Anti-TNF:Adalimumab (Subcutaneus)
* Drug: Anti-TNF discontinuation: Physiological saline solution


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients diagnosed with IBD by the usual criteria; both Crohn's and ulcerative colitis disease. Patients older than 18 years. In the case of patients with Crohn's disease the indication treatment with anti-TNF it must have been for luminal involvement (no perianal). Are currently in clinical remission. The clinical remission period with the drug at non-intensified dose it must have been at least 6 months. The administration of ≥10 mg/kg/8 weeks or 5 mg / kg / ≤ 4 weeks, in the case of infliximab, and 40 mg / week, in the case of adalimumab, is considered an intensified dose. At the time of inclusion, the patient should be receiving concomitant immunosuppressants (thiopurine or methotrexate) to anti-TNF treatment, and must have received these immunosuppressive drugs at stable doses for at least the last 3 months. In patients with Crohn's disease or ulcerative colitis disease, at baseline colonoscopy (made up to 3 months prior to the screening visit) should not be significant injuries. In the case of patients with Crohn's ileal or ileocolic disease, in magnetic resonance whole should not be significant injuries.(made up to 3 months prior to the screening visit) Exclusion Criteria: Age less than 18 years. Patients who have been treated with anti-TNF for other indication than the IBD. Patients with Crohn's disease in which the indication for treatment with anti-TNF has been the perianal involvement (or luminal and perianal both); or showing active perianal disease at the time of inclusion. Patients who are not receiving concomitant treatment with immunosuppressants (thiopurine or methotrexate) at the moment (and in the previous 3 months). Patients undergoing bowel resection surgery; therefore, patients who began anti-TNF therapy to prevent or treat postoperative recurrence in Crohn's disease will be excluded. Presence of significant endoscopic or radiological lesions Advanced chronic illness or any other condition that prevents the patient from coming to the clinic for monitoring or follow-up. Patients who are pregnant, breastfeeding or intending to become pregnant during the course of the study. Refusal to give consent for participation in the study.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Quadruple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Anti-TNF<br>Infliximab (Infusion 5mg/kg milligram(s)/Kilogram-Intravenous use) or Adalimumab (Subcutaneus 40 mg milligram(s)-subcutaneus) | Biological: Anti-TNF: Infliximab (Infusion)<br>* Infliximab (Infusion 5mg/kg milligram(s)/Kilogram-Intravenous use)(Visit1,visit 3,visit 4,visit 5, visit 6 and visit 7)<br>Biological: Anti-TNF:Adalimumab (Subcutaneus)<br>* Adalimumab (Subcutaneus 40 mg milligram(s)-subcutaneus)(Visit 1,visit 2,visit 3,visit 4,visit 5, visit 6 and visit 7).<br>|
| Placebo Comparator: Anti-TNF discontinuation (Placebo)<br>Physiological saline solution (Infusion-Intravenous use) or Physiological saline solution (Injection-subcutaneous use) | Drug: Anti-TNF discontinuation: Physiological saline solution<br>* Physiological saline solution (Infusion-Intravenous use)(Visit1,visit 3,visit 4,visit 5, visit 6 and visit 7)<br>Drug: Anti-TNF discontinuation: Physiological saline solution<br>* Physiological saline solution (Injection-subcutaneous use)(Visit 1,visit 2,visit 3,visit 4,visit 5, visit 6 and visit 7).<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Sustained clinical remission after one year of follow-up (after discontinuing or continuing treatment with anti-TNF). |  | Change at 12 months. | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Clinical activity assessment | On Crohn´s Disease: Measure by Crohn´s Disease Activity Index (CDAI) | Month 0, month 1, month 2, month 4, month 6, month 8, month 10, month 12 | 
| Endoscopic activity assessment | On Crohn´s Disease: Measure by Simplified endoscopic activity score for Crohn´s disease (SES-CD). | 12 Months. On the Month 0, month 12 or relapse | 
| Radiologic activity assessment | Measure by absence of contrast enhancement, edema or presence of ulcers | 12 Months. Month 0, month 12 or relapse | 
| Quality of life assessment | Measure by the Inflammatory Bowel Disease Questionnaire (IBDQ-9) | Month 0, month 1, month 2, month 4, month 6, month 8, month 10, month 12 | 
| The Work productivity and activity assessment | Measure by Spanish Work Productivity and Activity Impairment Questionnaire.This questionnaire assessments the sum of work time missed because IBD and impairment while working yields the overall work impairment (productivity loss) score. Scores are expressed as percentages of impairment/productivity loss, with higher scores indicating greater impairment. | Month 0, month 1, month 2, month 4, month 6, month 8, month 10, month 12 | 
| Clinical activity assessment | On the Ulcerative Colitis disease: Measure by Mayo Scoring System | Month 0, month 1, month 2, month 4, month 6, month 8, month 10, month 12 | 
| Endoscopic activity assessment | On the Ulcerative Colitis disease: Measure by Mayo endoscopic score. | 12 Months. On the Month 0, month 12 or relapse | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Crohn's Disease, Inflammatory bowel disease, Anti-TNF discontinuation, Ulcerative colitis