1. Appropriate maintenance treatment for Crohn's disease: Results of a multidisciplinary international expert panel — EPACT II.
- Author
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Juillerat, Pascal, Vader, John-Paul, Felley, Christian, Pittet, Valérie, Gonvers, Jean-Jacques, Mottet, Christian, Bemelman, Willem A., Lémann, Marc, Öresland, Tom, Michetti, Pierre, and Froehlich, Florian
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APPROPRIATENESS (Ethics) ,INFLAMMATORY bowel disease treatment ,MEDICAL statistics ,DISEASE remission ,MEDICAL specialties & specialists ,INFLAMMATORY bowel diseases ,METHOTREXATE - Abstract
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. [Copyright &y& Elsevier]
- Published
- 2009
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