Appropriate maintenance treatment for Crohn's disease: Results of a multidisciplinary international expert panel — EPACT II
Received 13 March 2009; received in revised form 13 May 2009; accepted 13 May 2009. published online 15 July 2009.
Abstract
Introduction
Biological therapy has dramatically changed management of Crohn's disease (CD). New data have confirmed the benefit and relative long-term safety of anti-TNFα inhibition as part of a regular scheduled administration programme. The EPACT appropriateness criteria for maintenance treatment after medically-induced remission (MIR) or surgically-induced remission (SIR) of CD thus required updating.
Methods
A multidisciplinary international expert panel (EPACT II, Geneva, Switzerland) discussed and anonymously rated detailed, explicit clinical indications based on evidence in the literature and personal expertise. Median ratings (on a 9-point scale) were stratified into three assessment categories: appropriate (7–9), uncertain (4–6 and/or disagreement) and inappropriate (1–3). Experts ranked appropriate medication according to their own clinical practice, without any consideration of cost.
Results
Three hundred and ninety-two specific indications for maintenance treatment of CD were rated (200 for MIR and 192 for SIR). Azathioprine, methotrexate and/or anti-TNFα antibodies were considered appropriate in 42 indications, corresponding to 68% of all appropriate interventions (97% of MIR and 39% of SIR). The remaining appropriate interventions consisted of mesalazine and a “wait-and-see” strategy. Factors that influenced the panel's voting were patient characteristics and outcome of previous treatment. Results favour use of anti-TNFα agents after failure of any immunosuppressive therapy, while earlier primary use remains controversial.
Conclusion
Detailed explicit appropriateness criteria (EPACT) have been updated for maintenance treatment of CD. New expert recommendations for use of the classic immunosuppressors as well as anti-TNFα agents are now freely available online (www.epact.ch). The validity of these criteria should now be tested by prospective evaluation.
aDepartment of Gastroenterology & Hepatology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
bHealthcare Evaluation Unit, Institute of Social & Preventive Medicine (IUMSP), Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
cDepartment of Surgery, Academic Medical Center, Amsterdam, The Netherlands
dDepartment of Gastroenterology, Hôpital Saint-Louis, Paris, France
eFaculty Division, Akershus University Hospital, University in Oslo, Oslo, Norway
fDepartment of GI Surgery, Akershus University Hospital, Lørenskog, Norway
gDepartment of Gastroenterology, University of Basle, Basle, Switzerland
Corresponding author. Pascal Juillerat, MD c/o Professor Pierre Michetti, Department of Gastroenterology & Hepatology, Centre Hospitalier Universitaire Vaudois, Rue du Bugnon 46, CH-1011 Lausanne, Switzerland. Tel.: +41 21 314 0690; fax: +41 21 314 0707.
1 The EPACT II Study Group (in alphabetical order): Erika Angelucci (Italy), Willem Bemelman (The Netherlands), Miquel Gassull (Spain), Franz Josef Heil (Germany), Marc Lémann (France), Tom Öresland (Norway), Colm O'Morain (Ireland), Yves Panis (France), Frank Seibold (Switzerland), Eduard Stange (Germany), Reinhold Stockbrügger (The Netherlands) and Boris Vucelic (Croatia).
ABSTRACT