Withdrawal of Immunosuppression in Crohn's Disease Treated With Scheduled Infliximab Maintenance
Article Outline
Dear Sir:
We commend Van Assche et al in their efforts to address the issue of withdrawing immunosuppression in patients with stable remission on combination treatment.1 Their article demonstrated a high loss of response to infliximab regardless of the use of immunosuppressant. We question whether smoking status might be a confounder. Smoking prevalence in the study was high, at 45% and 47.5% in the continued and discontinued immunosuppressant groups, respectively. We note with interest that smoking status was assessed by including nonsmoker, as opposed to smoker, status as seen in Table 3 of their article.
It is well accepted that smoking not only increases the predisposition to develop Crohn's disease, but also that smokers are less likely to respond to treatment.2, 3, 4, 5, 6 There is also a body of evidence that active smoking decreases the maintenance of response to infliximab.4, 5 Cosnes et al's 2001 paper6 demonstrated that smoking cessation decreased flares rates by as much as 65%. Other support for the effect of smoking on the course of Crohn's disease comes from the data surrounding postoperative resection with smokers having an odds ratio of close to 2.0 of relapse compared with nonsmokers.2, 7 Similarly, the risk of relapse was shown to decrease with cessation of smoking.8
The question raised is whether being a smoker, as opposed to a nonsmoker, affects failure of therapy and if this explains the high relapse rates in the absence of significant antibodies to infliximab?
References
- Withdrawal of immunosuppression in Crohn's disease treated with scheduled infliximab maintenance: a randomized trial. Gastroenterology. 2008;134:1861–1868
- Smoking habits and recurrence in Crohn's disease. Gastroenterology. 1994;106:643–648
- . A meta-analysis of the role of smoking in inflammatory bowel disease. Dig Dis Sci. 1989;34:1841–1854
- . An analysis of factors influencing short-term and sustained response to infliximab treatment for Crohn's disease. Aliment Pharmacol Ther. 2003;17:1451–1457
- Predictors of response to infliximab in patients with Crohn's disease. Gastroenterology. 2002;123:707–713
- Smoking cessation and the course of Crohn's disease: an intervention study. Gastroenterology. 2001;120:1093–1099
- Effects of cigarette smoking on recurrence of Crohn's disease. Gastroenterology. 1990;98:1123–1128
- Crohn's disease patients who quit smoking have a reduced risk of reoperation for recurrence. Am J Surg. 2004;187:219–225
The authors disclose no conflicts.
PII: S0016-5085(08)01854-4
doi:10.1053/j.gastro.2008.08.061
© 2008 AGA Institute. Published by Elsevier Inc. All rights reserved.
