Appropriateness of De-Escalation of Medical Therapy in Crohnʼs Disease Patients Who Are in Deep Remission: A RAND Panel Approach
Bibliographic record
Abstract
Introduction: Deep remission is a treatment goal for patients with Crohn's disease (CD) and marks a point at which de-escalation of medical therapy may be considered. There are limited data on how best to implement this approach. We aimed to provide guidance for clinicians on the appropriateness of de-escalating immunomodulator (IM) or anti-tumor necrosis factor (TNF) therapy in patients with CD who are in deep remission. Methods: A comprehensive literature review was presented to a panel of 12 international IBD experts. Appropriateness of de-escalation in patients in deep remission for at least 6 months was considered in 240 scenarios in 5 chapters: patients on combination therapy stopping anti-TNF therapy; on combination therapy stopping IM therapy; on combination therapy reducing IM to half the usual dose; stopping anti-TNF monotherapy; and stopping IM monotherapy. Using the RAND/UCLA modified Delphi method, panel members rated appropriateness of de-escalation in each scenario on a 1-9 scale (1-3 inappropriate, 4-6 uncertain, 7-9 appropriate) via a web-based survey, then met to discuss the topic and re-rated the scenarios. Disagreement was assessed using a validated index; scenarios with disagreement were rated as uncertain. Results: De-escalation was rated appropriate in only 32/240 scenarios (13.3%), including 19 scenarios of elderly patients on combination therapy stopping or dose-reducing IM therapy. De-escalation was rated inappropriate in 59/240 scenarios (24.6%), including 22 scenarios of patients on monotherapy and 35 scenarios of patients on combination therapy stopping anti-TNF therapy. More than 60% of scenarios (149/240) were rated uncertain, including 42 scenarios of patients with complicated CD on combination therapy stopping or dose-reducing IM. Disagreement was noted in one scenario: appropriateness of stopping thiopurine monotherapy in young males with uncomplicated CD. Selected examples are shown in Table. 1Table: Table. Appropriateness of de-escalating medical therapy in patients with CD (selected results)Conclusion: In patients with complicated CD, stopping any drug was considered appropriate in only a few scenarios. Stopping anti-TNF or IM in patients with uncomplicated CD on combination therapy was most often considered appropriate in elderly patients. Stopping monotherapy was not considered appropriate in any scenario. However, >60% of scenarios were rated uncertain based on current evidence. Additional data are required to better inform clinicians when and how to de-escalate medical therapy in patients with CD in deep remission.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.211 | 0.210 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.005 |
| Bibliometrics | 0.006 | 0.003 |
| Science and technology studies | 0.003 | 0.002 |
| Scholarly communication | 0.005 | 0.004 |
| Open science | 0.003 | 0.009 |
| Research integrity | 0.003 | 0.004 |
| Insufficient payload (model declined to judge) | 0.003 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".