Reenaers and colleagues reported the Anglo-Belgian experience in treating Crohn's disease (CD) with adalimumab (ADA) and immunosuppressors (IS). Unfortunately, the combination did not add a significant contribution in achieving clinical remission, but it led to a significant reduction in flares in the short- and long-term.
In my opinion, this study hasW four methodological flaws. First, the retrospective design does not permit definitive conclusions. Secondly, the design of the study, non-randomised, is quite surprising, because the approach to anti-tumour necrosis factor-alpha (TNFα) therapy, and therefore, its use in clinical practice may vary in different countries. Thirdly, the absence of any information about how many patients were IS naïve or under IS treatment at the beginning of the therapy with ADA. Finally, the absence of a subanalysis about the effect of different IS added to ADA on the course of the disease [the authors reported the use of azathioprine (AZA), mercaptopurine (MP) and methotrexate (MTX) as IS taken during the study].
After reading this article, I reviewed our CD patients treated with ADA in primary gastroenterology care. Our standard procedure is to prescribe AZA in combination with every anti-TNFα, not only to reduce the risk of adverse events at the beginning of the treatment, but also to speed up the effect of the therapy in obtaining clinical improvement. From December 2007 to December 2011, 24 CD patients have been treated with ADA (10 already under AZA treatment), and 22/24 (91.66%) achieved remission within 3 months.
Thus, should IS be started with AZA to reduce adverse events, similar to with infliximab, or to speed up the effect of the therapy? I feel that this approach should be considered whenever ADA is prescribed in CD patients.