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. 2023 Oct;165(4):976-985.e3.
doi: 10.1053/j.gastro.2023.05.051. Epub 2023 Jun 13.

Early Ileocecal Resection for Crohn's Disease Is Associated With Improved Long-term Outcomes Compared With Anti-Tumor Necrosis Factor Therapy: A Population-Based Cohort Study

Manasi Agrawal  1 , Anthony C Ebert  2 , Gry Poulsen  2 , Ryan C Ungaro  3 , Adam S Faye  4 , Tine Jess  5 , Jean-Frederic Colombel  3 , Kristine H Allin  5
Affiliations

Early Ileocecal Resection for Crohn's Disease Is Associated With Improved Long-term Outcomes Compared With Anti-Tumor Necrosis Factor Therapy: A Population-Based Cohort Study

Manasi Agrawal et al. Gastroenterology. 2023 Oct.

Abstract

Background & aims: Early Crohn's disease (CD) treatment involves anti-tumor necrosis factor (TNF) agents, whereas ileocecal resection (ICR) is reserved for complicated CD or treatment failure. We compared long-term outcomes of primary ICR and anti-TNF therapy for ileocecal CD.

Methods: Using cross-linked nationwide registers, we identified all individuals diagnosed with ileal or ileocecal CD between 2003 and 2018 and treated with ICR or anti-TNF agents within 1 year of diagnosis. The primary outcome was a composite of ≥1 of the following: CD-related hospitalization, systemic corticosteroid exposure, CD-related surgery, and perianal CD. We conducted adjusted Cox's proportional hazards regression analyses and determined the cumulative risk of different treatments after primary ICR or anti-TNF therapy.

Results: Of 16,443 individuals diagnosed with CD, 1279 individuals fulfilled the inclusion criteria. Of these, 45.4% underwent ICR and 54.6% received anti-TNF. The composite outcome occurred in 273 individuals (incidence rate, 110/1000 person-years) in the ICR group and in 318 individuals (incidence rate, 202/1000 person-years) in the anti-TNF group. The risk of the composite outcome was 33% lower with ICR compared with anti-TNF (adjusted hazard ratio, 0.67; 95% confidence interval, 0.54-0.83). ICR was associated with reduced risk of systemic corticosteroid exposure and CD-related surgery, but not other secondary outcomes. The proportion of individuals on immunomodulator, anti-TNF, who underwent subsequent resection, or were on no therapy 5 years post-ICR was 46.3%, 16.8%, 1.8%, and 49.7%, respectively.

Conclusion: These data suggest that ICR may have a role as first-line therapy in CD management and challenge the current paradigm of reserving surgery for complicated CD refractory or intolerant to medications. Yet, given inherent biases associated with observational data, our findings should be interpreted and applied cautiously in clinical decision making.

Keywords: Anti-Tumor Necrosis Factor Agent; Crohn's Disease; Ileocecal Resection; Inflammatory Bowel Disease; Surgery.

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Conflict of interest statement

The corresponding author confirms on behalf of all authors that there have been no involvements that might raise the question of bias in the work reported or in the conclusions, implications, or opinions stated.

MA reports no conflict of interest.

ACE reports no conflict of interest.

GP reports no conflict of interest.

RCU has served as a consultant for AbbVie, Bristol Myers Squibb, Janssen, Pfizer, and Takeda and has received research grants from AbbVie, Boehringer Ingelheim, Bristol Myers Squibb, and Pfizer.

ASF reports no conflict of interest.

TJ reports no conflict of interest.

JFC reports receiving research grants from AbbVie, Janssen Pharmaceuticals and Takeda; receiving payment for lectures from AbbVie, Amgen, Allergan, Inc. Ferring Pharmaceuticals, Shire, and Takeda; receiving consulting fees from AbbVie, Amgen, Arena Pharmaceuticals, Boehringer Ingelheim, Bristol Myers Squibb, Celgene Corporation, Eli Lilly, Ferring Pharmaceuticals, Galmed Research, Glaxo Smith Kline, Geneva, Iterative Scopes, Janssen Pharmaceuticals, Kaleido Biosciences, Landos, Otsuka, Pfizer, Prometheus, Sanofi, Takeda, TiGenix,; and hold stock options in Intestinal Biotech Development.

KHA reports no conflict of interest.

Figures

Figure 1:
Figure 1:
Patient flow diagram Abbreviations: CD, Crohn’s disease; anti-TNF, anti-tumor necrosis factor; ICR, ileocecal resection.
Figure 2:
Figure 2:
Kaplan Meier cumulative incidence estimates of the composite outcome including Crohn’s disease (CD)-related hospitalization, systemic corticosteroid exposure, CD-related surgery, and perianal CD in the groups that underwent ileocecal resection or received anti-TNF therapy as primary treatment for CD within one year of diagnosis. ICR, ileocecal resection; TNF: tumor necrosis factor.
Figure 3.
Figure 3.
Kaplan -Meier cumulative incidence estimates of secondary outcomes (a) Crohn’s disease (CD)-related hospitalization (b) systemic corticosteroid exposure (c) CD-related surgery, and (d) perianal CD in the groups that underwent ileocecal resection and received anti-TNF therapy as primary treatment for CD within one year of diagnosis. ICR, ileocecal resection; TNF: tumor necrosis factor.
Figure 4.
Figure 4.
Unadjusted incidence rates (IR), and adjusted hazard ratios (aHR) for the composite outcome for ICR group compared to the anti-TNF group, stratified by sex, age at diagnosis, year of treatment, corticosteroid use, immunomodulator use, all in the year prior to primary treatment. The hazard ratios are adjusted for age at diagnosis, sex, year of treatment, the number of hospital contacts for any indication, the number of unique prescription medications, systemic corticosteroid exposure, and immunomodulator exposure, all in the year prior to primary treatment. When stratifying by age, age was adjusted for in discretized age categories. P values are p for interaction.
Figure 5.
Figure 5.
Kaplan -Meier cumulative incidence and survival estimates for different medical treatments and surgery after primary therapy of (a) ileocecal resection and (b) anti-TNF therapy. The outcomes “Anti-TNF”, “ICR”, and “immunomodulator” (panel a) and “switch to another biologic” and “ICR” (panel b) are not mutually exclusive. ICR, ileocecal resection; TNF: tumor necrosis factor
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References

    1. Torres J, Mehandru S, Colombel JF, et al. Crohn’s disease. Lancet 2017;389:1741–1755. - PubMed
    1. Agrawal M, Spencer EA, Colombel JF, et al. Approach to the management of recently diagnosed inflammatory bowel disease patients: a user’s guide for adult and pediatric gastroenterologists. Gastroenterology 2021. - PMC - PubMed
    1. Singh S, Murad MH, Fumery M, et al. Comparative efficacy and safety of biologic therapies for moderate-to-severe Crohn’s disease: a systematic review and network meta-analysis. Lancet Gastroenterol Hepatol 2021;6:1002–1014. - PMC - PubMed
    1. Narula N, Wong ECL, Dulai PS, et al. Comparative Effectiveness of Biologies for Endoscopic Healing of the Ileum and Colon in Crohn’s Disease. Am J Gastroenterol 2022;117:1106–1117. - PubMed
    1. Ko Y, Paramsothy S, Yau Y, et al. Superior treatment persistence with ustekinumab in Crohn’s disease and vedolizumab in ulcerative colitis compared with anti-TNF biological agents: real-world registry data from the Persistence Australian National IBD Cohort (PANIC) study. Aliment Pharmacol Ther 2021;54:292–301. - PubMed

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