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Aratari A, Scribano ML, Pugliese D, Baccolini V, De Biasio F, Verna S, Morretta C, Festa S, Armuzzi A, Papi C. Crohn's disease after surgery: Changes in post-operative management strategies over time and their impact on long-term re-operation rate-A retrospective multicentre real-world study. Aliment Pharmacol Ther 2024; 59:1579-1588. [PMID: 38616417 DOI: 10.1111/apt.18001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/09/2023] [Accepted: 04/02/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND Few data are available addressing the impact of post-operative management of Crohn's disease (CD) on long-term clinical course. AIM To assess the evolution of post-operative management strategies over the last 40 years and their impact on the re-operation rate of CD. METHODS We included 657 patients with CD who had undergone their first radical ileo-caecal resection between 1980 and 2020. Three cohorts were defined according to year of surgery: cohort 1 (1980-1998; n = 198), cohort 2 (1999-2009; n = 218) and cohort 3 (2010-2020; n = 241). We estimated exposure to immunomodulators and anti-TNFα agents after surgery and rates of re-operation using Kaplan-Meier survival analyses. We used Cox proportional hazards regression to assess the association of clinical variables with time to re-operation. RESULTS Immunosuppressants, (IMMs) and anti-TNFα exposure within 5 years after surgery increased significantly from cohort 1 to cohort 2 and cohort 3 (IMMs: 1.6%, 38.2% and 28.0%, respectively, p < 0.001; anti-TNFα: 0.0%, 20.7% and 52.0%, respectively, p < 0.001). There was no significant difference across cohorts regarding the cumulative probability of re-operation within 5 and 10 years. Multivariate analysis identified IMMs/anti-TNFα exposure before the first surgery (HR 9.15; 95% CI 2.77-30.21) and post-operatively (HR: 0.24; 95% CI 0.07-0.74) as variables associated with the risk of re-operation. However, these associations had a time-varying effect and become non-significant after 5 and 2 years after surgery, respectively. CONCLUSION Despite increased post-operative use of IMMs and anti-TNFα agents in the last two decades, the impact of these strategies on the risk of long-term re-operation rate has been modest.
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Affiliation(s)
| | | | - Daniela Pugliese
- IBD Unit, Digestive Disease Center (CEMAD) Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Valentina Baccolini
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | | | - Serena Verna
- Gastroenterology Unit, San Camillo-Forlanini Hospital, Rome, Italy
| | - Chiara Morretta
- IBD Unit, Digestive Disease Center (CEMAD) Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | | | - Alessandro Armuzzi
- IBD Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Claudio Papi
- IBD Unit, San Filippo Neri Hospital, Rome, Italy
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Wewer MD, Jansson S, Malham M, Burisch J, Wewer V. Disease Activity Patterns of Paediatric Inflammatory Bowel Disease: A Danish Nationwide Cohort Study (1996-2018). J Crohns Colitis 2024; 18:246-255. [PMID: 37603029 DOI: 10.1093/ecco-jcc/jjad144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND AND AIMS Inflammatory bowel diseases [IBD] are heterogeneous in the frequency and severity of their flare-ups. We aimed to describe disease activity patterns in a Danish nationwide paediatric IBD cohort. METHODS Paediatric patients [<18 years at diagnosis] with Crohn's disease [pCD] or ulcerative colitis [pUC] in the study period from 1996 to 2018 were identified in national registers. Disease activity [severe, moderate-to-mild, remission] was assessed at diagnosis according to medications prescribed, hospitalizations, and surgeries. RESULTS In total, 1965 pCD and 1838 pUC incident patients were included in the cohort. At diagnosis, severe disease activity was found in 87%/80% of pCD/pUC and in addition 6.1% of pUC patients had undergone a colectomy during the first year after diagnosis. Five years after diagnosis, the annual proportions of pCD/pUC with no disease activity were 70%/61%, and 10 years after diagnosis the proportions were 72%/64%. Colectomy was required in 6.1, 12, and 16% of pUC patients after 1, 5 and 10 years. No improvement of disease activity was seen in the proportion of prevalent pCD [N = 2515] and pUC [N = 2428] in the study period 2000-2018 concomitant with the introduction of biological treatment. However, decreasing disease activity was the most common pattern in both pCD and pUC [43 and 47%], respectively. CONCLUSIONS pIBD was characterized by a high proportion of patients with severe activity at diagnosis, followed by an improvement after 5 and 10 years of follow-up. Notably, the proportion of patients with no disease activity was unchanged when biological treatment was introduced and the number of colectomies in pUC remained high.
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Affiliation(s)
- Mads Damsgaard Wewer
- Gastro Unit, Medical Division, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
- Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Hvidovre Hospital, Hvidovre, Denmark
| | - Sabine Jansson
- Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Hvidovre Hospital, Hvidovre, Denmark
- Department of Paediatrics and Adolescent Medicine, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Mikkel Malham
- Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Hvidovre Hospital, Hvidovre, Denmark
- Department of Paediatrics and Adolescent Medicine, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Johan Burisch
- Gastro Unit, Medical Division, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
- Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Hvidovre Hospital, Hvidovre, Denmark
| | - Vibeke Wewer
- Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Hvidovre Hospital, Hvidovre, Denmark
- Department of Paediatrics and Adolescent Medicine, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Youssef M, Dong K, Lee SJ, Narula N. Histological Remission Placebo Rates in Ulcerative Colitis Trials: A Systematic Review and Meta-analysis. Inflamm Bowel Dis 2024; 30:125-131. [PMID: 36753516 DOI: 10.1093/ibd/izad013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Indexed: 02/09/2023]
Abstract
BACKGROUND High histologic remission rates have been reported with placebos in randomized controlled trials (RCTs) evaluating ulcerative colitis (UC) therapies and have varied based on trial designs. We performed a systematic review and meta-analysis to quantify placebo histological remission rates and identify factors influencing those rates. METHODS MEDLINE, EMBASE, and the Cochrane library were searched from inception of the databases until December 2021. We included placebo-controlled RCTs of adult patients with UC treated with aminosalicylates, corticosteroids, immunosuppressives, biologics, and small molecules. We pooled estimates using a random-effects model and performed subgroup analysis and meta-regression to evaluate the effect of different covariates on placebo rates. RESULTS Thirty-three studies (30 induction and 3 maintenance) were included. The overall placebo histological remission rate was 15.7% (95% confidence interval, 12.9%-19%) across all 33 studies. High heterogeneity was observed among studies with I2 = 62.10%. The pooled estimate of histological remission was 15.8% in induction studies and 14.5% in maintenance studies. Subgroup analysis revealed statistically significant differences in placebo rates when accounting for background medications, the intervention drug class, and disease severity (P = .041, .025, and .025, respectively). There was no statistical difference between induction vs maintenance studies or between different histological scales (P = .771, and .075, respectively). CONCLUSIONS Placebo histological remission rates range from 13% to 19% in UC RCTs, but studies are highly heterogeneous. Factors found to influence placebo rates include presence of background medications, the drug used, and the disease severity. These observations inform future trial designs to minimize placebo rates and reduce heterogeneity.
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Affiliation(s)
- Michael Youssef
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Kelly Dong
- Department of General Surgery, McMaster University, Hamilton, ON, Canada
| | - So Jeong Lee
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Neeraj Narula
- Department of Medicine (Division of Gastroenterology) and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton ON, Canada
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Wewer MD, Arp L, Sarikaya M, Felding OK, Vind I, Pedersen G, Mertz-Nielsen A, Kiszka-Kanowitz M, Boysen T, Theede K, Petersen AM, Nordgaard-Lassen I, Bendtsen F, Burisch J. The Use and Efficacy of Biological Therapies for Inflammatory Bowel Disease in a Danish Tertiary Centre 2010-2020. CROHN'S & COLITIS 360 2022; 4:otac041. [PMID: 36778517 PMCID: PMC9802297 DOI: 10.1093/crocol/otac041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Indexed: 11/06/2022] Open
Abstract
Background Patients with inflammatory bowel disease (IBD) who receive biologicals frequently experience lack or loss of response. Our aim was to describe the use and efficacy of biological therapy in a tertiary IBD center. Methods We included all bio-naive IBD patients who initiated biological therapy between 2010 and 2020 at our centre. Their medical records were reviewed. Results The population consisted of 327 Crohn's disease (CD) patients, 291 ulcerative colitis (UC) patients, and 3 patients with IBD unclassified (IBDU). The median follow-up was 3 years (interquartile range = 2-5) after initiating therapy. The annual number of patients initiating biological therapy rose from 29 (2010) to 85 (2019). Most patients (457, 73.6%) received 1 biological drug; 164 (26.4%) patients received 2 or more biologicals. Primary lack of response was observed in 36.4% (106/291) and 17.4% (57/327) of UC and CD patients; loss of response was observed in 27.1% (79/291) and 31.5% (103/327) of UC and CD patients, respectively. The 5-year surgery rates were 26.6% and 20.4% in UC and CD patients, respectively. Multivariate Cox regression showed that treatment with thiopurine reduced the likelihood of needing to switch biological therapy, requiring surgery or corticosteroids in UC patients (HR: 0.745, 95% CI: 0.559-0.993), but not in CD patients (HR: 0.996, 95% CI: 0.736-1.349). Conclusions The annual number of IBD patients initiated on biological therapy increased considerably between 2010 and 2020. One-quarter of these patients required surgery after 5 years. Our findings suggest a beneficial effect of concurrent thiopurines for UC patients receiving biologicals, but this was not found for CD patients. This effect in UC patients was not observed when we included patients initiating thiopurines up to 6 months after the introduction of biological therapy.
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Affiliation(s)
- Mads Damsgaard Wewer
- Address correspondence to: Mads Damsgaard Wewer, Blegdamsvej 3B, 2200 Copenhagen, Denmark ()
| | - Laura Arp
- Medical Faculty, University of Copenhagen, Copenhagen, Denmark,Gastro Unit, Medical Division, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark,Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Hvidovre Hospital, Hvidovre, Denmark
| | - Melek Sarikaya
- Medical Faculty, University of Copenhagen, Copenhagen, Denmark,Gastro Unit, Medical Division, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark,Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Hvidovre Hospital, Hvidovre, Denmark
| | - Oluf Krautwald Felding
- Medical Faculty, University of Copenhagen, Copenhagen, Denmark,Gastro Unit, Medical Division, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark,Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Hvidovre Hospital, Hvidovre, Denmark
| | - Ida Vind
- Gastro Unit, Medical Division, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark,Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Hvidovre Hospital, Hvidovre, Denmark
| | - Gitte Pedersen
- Gastro Unit, Medical Division, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark,Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Hvidovre Hospital, Hvidovre, Denmark
| | - Anette Mertz-Nielsen
- Gastro Unit, Medical Division, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark,Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Hvidovre Hospital, Hvidovre, Denmark
| | - Marianne Kiszka-Kanowitz
- Gastro Unit, Medical Division, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark,Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Hvidovre Hospital, Hvidovre, Denmark
| | - Trine Boysen
- Gastro Unit, Medical Division, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark,Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Hvidovre Hospital, Hvidovre, Denmark
| | - Klaus Theede
- Gastro Unit, Medical Division, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark,Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Hvidovre Hospital, Hvidovre, Denmark
| | - Andreas Munk Petersen
- Gastro Unit, Medical Division, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark,Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Hvidovre Hospital, Hvidovre, Denmark,Department of Clinical Microbiology, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Inge Nordgaard-Lassen
- Gastro Unit, Medical Division, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark,Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Hvidovre Hospital, Hvidovre, Denmark
| | - Flemming Bendtsen
- Gastro Unit, Medical Division, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark,Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Hvidovre Hospital, Hvidovre, Denmark
| | - Johan Burisch
- Gastro Unit, Medical Division, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark,Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Hvidovre Hospital, Hvidovre, Denmark
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Baelum JK, Qvist N, Ellebaek MB. Ileorectal anastomosis in patients with Crohn's disease. Postoperative complications and functional outcome-a systematic review. Colorectal Dis 2021; 23:2501-2514. [PMID: 34309170 DOI: 10.1111/codi.15839] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 04/27/2021] [Accepted: 07/20/2021] [Indexed: 01/10/2023]
Abstract
AIM The objective of this systematic review was to investigate the outcomes of ileorectal anastomosis (IRA) in Crohn's disease and to clarify whether there are any time-related trends in outcome measures. The primary outcomes are risk of anastomotic leakage, death, clinical recurrence and subsequent diverting or permanent stoma and/or proctectomy. Secondary end-points are quality of life and functional outcome. METHODS Systematic searches were conducted using the Cochrane Library, Embase and MEDLINE. The complete search strategy is uploaded online at http://www.crd.york.ac.uk/prospero/. Human studies in English with over five subjects were included and no limit was set regarding the date of publication. All relevant studies were screened by two reviewers. The web-based software platform www.covidence.org was used for primary screening of the title, abstract, full-text review and data extraction. RESULTS The search identified 2231 unique articles. After the screening process, 37 remained. Key results were an overall anastomotic leak rate of 6.4%; cumulative rates of clinical recurrence of 43% and 67% at 5 and 10 years, respectively; an overall rate of proctectomy of 18.9%; and subsequent ileostomy required in 18.8%. Only one study presented useful data on quality of life. Recurrence rates remained stable over time. A small decline in the anastomotic leak rate was found. CONCLUSIONS Only minor improvements in the outcomes of IRA in patients with Crohn´s disease have occurred during the past 50 years regarding anastomotic leakage and recurrence, except for a slight increase in the rate of a functioning IRA. These results call for implementation guidelines in patient selection for IRA and postoperative medical treatment and follow-up.
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Affiliation(s)
| | - Niels Qvist
- Surgical Department A, Odense University Hospital, Odense, Denmark
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Alulis S, Vadstrup K, Olsen J, Jørgensen TR, Qvist N, Munkholm P, Borsi A. The cost burden of Crohn's disease and ulcerative colitis depending on biologic treatment status - a Danish register-based study. BMC Health Serv Res 2021; 21:836. [PMID: 34407821 PMCID: PMC8371832 DOI: 10.1186/s12913-021-06816-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 07/23/2021] [Indexed: 11/13/2022] Open
Abstract
Background Patients diagnosed with inflammatory bowel disease may be treated with biologics, depending on several medical and non-medical factors. This study investigated healthcare costs and production values of patients treated with biologics. Methods This national register study included patients diagnosed with Crohn’s disease (CD) and ulcerative colitis (UC) between 2003 and 2015, identified in the Danish National Patient Register (DNPR). Average annual healthcare costs and production values were compared for patients receiving biologic treatment or not, and for patients initiating biologic treatment within a year after diagnosis or at a later stage. Cost estimates and production values were based on charges, fees and average gross wages. Results Twenty-six point one percent CD patients and ten point seven percent of UC patients were treated with biologics at some point in the study period. Of these, 46.4 and 45.5 % of patients initiated biologic treatment within the first year after diagnosis. CD and UC patients treated with biologics had higher average annual healthcare costs after diagnosis compared to patients not treated with biologics. CD patients receiving biologics early had lower production values both ten years before and eight years after treatment initiation, compared to patients receiving treatment later. UC patients receiving biologics early had lower average annual production values the first year after treatment initiation compared to UC patients receiving treatment later. Conclusions CD and UC patients receiving biologic treatment had higher average annual healthcare costs and lower average annual production values, compared to patients not receiving biologic treatment. The main healthcare costs drivers were outpatient visit costs and admission costs.
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Affiliation(s)
- Sarah Alulis
- Janssen-Cilag, Bregnerødvej 133, 3460, Birkerød, Denmark.
| | | | | | | | - Niels Qvist
- Surgical Department A and IBD Care, Odense University Hospital, Odense, Denmark
| | - Pia Munkholm
- Gastroenterology Department, North Zealand University Hospital, Frederikssund, Denmark
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