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Editor's Correspondence
March 24, 2008

Risks of Combining Immunosuppressive and Biological Treatments in Inflammatory Bowel Disease

Arch Intern Med. 2008;168(6):667. doi:10.1001/archinte.168.6.667

Sorrentino et al1 report the results of infliximab with low-dose methotrexate for the prevention of postsurgical recurrence of ileocolonic Crohn disease (CD). The authors elected to coadminister methotrexate because it is known to reduce the long-term immunogenicity of infliximab.2 This is true only with episodic treatment with infliximab. Despite the observation that therapy with concomitant immunosuppressive agents reduces the development of antibodies against biological treatments, the authors have not significantly altered the response to infliximab3 in the treatment of CD when the agents are administered as an induction course followed by scheduled maintenance treatment. Recently, Maser et al4 demonstrated that the rate of clinical remission was higher for patients with a detectable trough serum concentration of infliximab compared with patients in whom serum infliximab was undetectable, including those without antibodies (82% vs 6%; P < .001). In this study, concurrent immunomodulators did not alter outcomes.4 A preliminary report from Van Assche et al5 suggested that the immunosuppressive therapy could be discontinued after 6 months with no effect on the loss of response to infliximab over 2 years. So the concept of combination immunosuppressive therapy needs to be discussed in light of the expanding reports of potential increases in severe infections and neoplasms.6