Patient Outcomes after Anti-TNF-α Drugs for Crohn's Disease

Nazila Assasi; Gord Blackhouse; Feng Xie; John K Marshall; E Jan Irvine; Kathryn Gaebel; Diana Robertson; Kaitryn Campbell; Rob Hopkins; Ron Goeree


Expert Rev Pharmacoeconomics Outcomes Res. 2010;10(2):163-175. 

In This Article

Abstract and Introduction


Crohn's disease (CD) is a chronic inflammatory bowel disease with a relatively high prevalence rate in North America. More than 50% of CD patients require surgery at some stage of their disease. Anti-TNF-α drugs are increasingly being used in patients with CD who have had an inadequate response to conventional therapy. Treatment with anti-TNF-α agents aims at improving symptom control and reducing the need for hospitalization and surgery. This review examines the clinical effectiveness of three anti-TNF-α agents (infliximab, adalimumab and etanercept) in moderate and severe CD. The review further considers the evidence for the harms and benefits associated with switching from one anti-TNF-α agent to another and strategies to optimize the timing of therapy.


Crohn's disease (CD) is a chronic inflammatory disease of the gastrointestinal tract with unknown etiology.[1] CD is characterized by transmural inflammation that may affect any part of the gastrointestinal tract. Symptoms depend on the location, extent and severity of involvement, and can include abdominal pain, nausea, anorexia and weight loss. The presentation of CD is often subtle, leading to a delay in diagnosis. In Canada, CD affects approximately 233.7 per 100,000 people, with an incidence of 13.4 per 100,000 each year.[2]

As there is no cure for CD, patients often need continuous medication and long-term follow-up. Medical management of CD involves treatment of acute inflammatory symptoms followed by maintenance treatment to prolong remission and heal the gastrointestinal mucosa. The therapeutic approach is determined based on the severity of the symptoms and the degree of intestinal involvement. The most common treatments that are used for maintenance of remission are 5-aminosalicylic acid agents, immunomodulatory therapy and biologic therapy.[3] Antibiotics have been shown to be effective in the management of CD[4–6] but the role of probiotics remains unclear.[6,7] Surgical management may be necessary in poorly controlled or complex recurrent acute cases of CD.

Three biological treatments (etanercept, infliximab and adalimumab) are categorized as anti-TNF-α drugs.[8] Infliximab and adalimumab are increasingly being used in patients with CD who have an inadequate response to conventional therapy. In Canada, infliximab[9–12] and adalimumab[13] are approved for the treatment of CD; however, etanercept is not.

We conducted a systematic review to evaluate the comparative effectiveness of anti-TNF-α drugs in CD patients with inadequate response to conventional therapies. We also looked at the evidence for the optimal timing of anti-TNF-α, and the harms and benefits associated with switching from one anti-TNF-α to another.


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