Background: Inflammatory bowel disease is a chronic relapsing and remitting inflammation of the bowel. Tumour necrosis factor α - antagonists are safe and effective in the treatment of inflammatory bowel disease. Indications and outcomes with consecutive anti-tumour necrosis factor agents, although often used, are not clear. Since data for this treatment choice is scarce, we set out to evaluate the use of consecutive anti-tumour necrosis factor agents in patients with inflammatory bowel disease.

Method: A national registry established by The South African Gastroenterology Society was used for retrospective data extraction in patients with consecutive anti-tumour necrosis factor agent use. Demographic, clinical details, treatment outcomes and adverse events were documented.

Results: Eight-six (7.5%) of 1150 patients received consecutive tumour necrosis factor-antagonists. There were 41 (48%) patients with Crohn’s disease and 45 (52%) with ulcerative colitis. Gender distribution was equal with 45 (52%) male and 41 (48%) female patients. Patients failed the first anti-tumour necrosis factor agent over 30 months, but remission rates improved with second agent. Immunomodulator therapy had no effect of anti-tumour necrosis agent discontinuation rates. Adalimumab treatment had higher rate of dose escalation/switching as well as adverse events compared to infliximab. Most patients remained in clinical remission except a few with CD who required surgery.

Conclusion: Using a second anti-tumour necrosis factor agent when the first agent failed is often necessary in inflammatory bowel disease. Although cost-effective, this strategy lacks clarity. Patient selection is crucial and therapeutic drug monitoring should be central in that decision. Adalimumab is associated with higher rates of dose escalation and a worse side-effect profile. Patients with UC switched earlier compared to CD.

Crohn's disease, Ulcerative colitis, TNF-antagonists