Should Xeljanz (tofacitinib) be continued in a patient with Crohn's disease who has achieved clinical remission?

Continuation of Xeljanz (Tofacitinib) in Crohn's Disease After Achieving Clinical Remission

Xeljanz (tofacitinib) should be continued in patients with Crohn's disease who have achieved clinical remission to maintain remission and prevent disease relapse, following the same principle established for other biologic therapies in Crohn's disease management.

Evidence-Based Rationale for Continuing Therapy

While the provided guidelines do not specifically mention tofacitinib (Xeljanz) for Crohn's disease, they establish a clear pattern for biologic therapy management that can be applied to Xeljanz:

1. Maintenance Therapy Principle: The Canadian Association of Gastroenterology guidelines strongly recommend continued therapy for patients who achieve symptomatic response with biologic induction therapy 1. This principle applies to:

   • Anti-TNF therapy (Strong recommendation, high-quality evidence)
   • Vedolizumab (Strong recommendation, moderate-quality evidence)
   • Ustekinumab (Strong recommendation, moderate-quality evidence)

2. Disease Relapse Risk: Discontinuing biologic therapy in Crohn's disease leads to predictable relapse in the majority of patients. Studies of infliximab show that 50% of patients relapse within 477 days after discontinuation 2.

Management Algorithm for Patients in Remission

1. Continue Maintenance Therapy:

   • Maintain the effective dose that achieved remission
   • Monitor for continued efficacy and adverse effects
   • Perform periodic assessment of disease activity using clinical symptoms, inflammatory markers, and endoscopic evaluation when appropriate

2. Monitoring Parameters During Maintenance:

   • Clinical symptoms (bowel movements, abdominal pain)
   • Laboratory markers (CRP, fecal calprotectin)
   • Periodic endoscopic assessment to confirm mucosal healing

3. Duration of Therapy:

   • Long-term maintenance therapy is generally recommended
   • No defined endpoint for discontinuation in patients maintaining remission

Potential Consequences of Discontinuation

• High risk of disease relapse (>50% within 1-2 years)
• Return of symptoms and inflammation
• Potential for disease complications (strictures, fistulas)
• Risk of immunogenicity if therapy is restarted after a drug holiday
• Possible decreased efficacy upon retreatment

Special Considerations

• Deep Remission: Patients who achieve both clinical and endoscopic remission may have better long-term outcomes but still benefit from continued therapy
• Combination Therapy: If Xeljanz is being used with immunomodulators, the combination may be more effective but carries additional risks that should be monitored
• Safety Monitoring: Regular laboratory monitoring should continue during maintenance therapy

Pitfalls to Avoid

1. Premature Discontinuation: Stopping therapy based solely on symptom improvement without confirming mucosal healing
2. Inadequate Monitoring: Failing to monitor for disease activity during maintenance therapy
3. Dose Reduction Without Evidence: Arbitrarily reducing the dose without clinical evidence supporting this approach
4. Ignoring Adverse Effects: Not monitoring for potential long-term adverse effects of continued therapy

The evidence strongly supports that patients with Crohn's disease who achieve remission on biologic therapy should continue maintenance therapy to preserve remission and prevent complications associated with disease relapse.