Anti-tumor Necrosis Factor Therapy in Inflammatory Bowel Disease: Effectiveness and Challenges in a Moroccan Tertiary...

Anti-tumor necrosis factor alpha (anti-TNF-α) agents have transformed the management of moderate-to-severe inflammatory bowel disease (IBD). However, primary non-response, secondary loss of response, and access-related barriers remain important challenges, especially in resource-limited settings.

The aim of this study was to evaluate the real-life effectiveness of anti-TNF-α therapy in patients with IBD followed in a Moroccan tertiary gastroenterology department and to describe clinical and access-related challenges associated with treatment outcomes in a resource-limited setting.

We conducted a retrospective single-center study in the Department of Gastroenterology and Hepatology at Mohammed VI University Hospital, Marrakech, from September 2019 to March 2024. Patients with Crohn's disease (CD) or ulcerative colitis (UC) who were treated with anti-TNF-α therapy and followed in the department were included. Demographic, clinical, therapeutic, and outcome data were collected from medical records. The analysis was primarily descriptive, and results were expressed as numbers and percentages.

Seventy-nine patients were included. The mean age was 36 years, with a range of 11 to 73 years. Of the 79 patients, 43 (54%) were men and 36 (46%) were women. CD was present in 60 patients (76%) and UC in 19 patients (24%). Among patients with CD, ileocolonic involvement was observed in 31 of 60 patients (51.6%), a stenosing phenotype in 30 of 60 patients (50%), and perianal lesions in 34 of 60 patients (56.6%). Among patients with UC, pancolitis was present in 10 of 19 patients (52.6%). Infliximab was used in 56 of 79 patients (71%), adalimumab in 19 of 79 patients (24%), and golimumab in four of 79 patients (5%). Combination therapy with azathioprine was used in 45 of 79 patients (57%). After a mean follow-up of 30 months, primary non-response occurred in 15 of 79 patients (19%), and secondary loss of response occurred in 18 of 79 patients (22.8%). Management strategies included optimization, intra-class switching, ustekinumab, and surgery in selected cases. Six of 79 patients (7.6%) underwent treatment de-escalation. Treatment was discontinued because of financial constraints in 18 of 79 patients (22.8%), and 6 of 79 patients (7.6%) were lost to follow-up. Perianal lesions, colonic involvement, previous intestinal resection greater than 50 cm, and active smoking were observed among patients with treatment failure or loss of response and were interpreted descriptively.

Anti-TNF-α therapy showed real-life effectiveness in this tertiary-center cohort despite a high proportion of severe IBD phenotypes. Primary non-response and secondary loss of response remain frequent challenges. Severe disease features and access-related barriers may influence long-term outcomes. Close monitoring, individualized management, reactive therapeutic drug monitoring when available, and improved access to biologics are essential to optimize care in resource-limited settings.