Azathioprine Maintains First Remission in Newly Diagnosed Pediatric Crohn's Disease

Abstract

6-Mercaptopurine (6-MP) maintains remission in pediatric Crohn's disease (CD). Azathioprine, a prodrug of 6-MP, is used for maintenance of remission of CD in Europe. We evaluated to what extent azathioprine is used in newly diagnosed pediatric CD patients and whether maintenance of remission differed between patients using azathioprine or not. Charts of children (diagnosed 1998Y2003, follow-up Q 18 mo) were reviewed. Active disease was defined as Pediatric Crohn's Disease Activity Index (PCDAI) greater than 10 or systemic corticosteroid use. Remission was defined as PCDAI 10 or less without use of corticosteroids. Eighty-eight children (55M/33F, age 12 T 3 yr) were included. Seventy-two (82%) patients received azathioprine during the follow-up period (38 T 17 mo). Patients diagnosed after 2000 received azathioprine significantly earlier during the course of disease compared with those diagnosed earlier (median, at 233 vs. 686 days; P G 0.05). At initial presentation, moderate-severe disease activity and prescription of corticosteroids were more prevalent in patients using azathioprine compared with nonazathioprine patients (75% vs. 52%; P G 0.05; and 89% vs. 58%; P G 0.005, respectively). Duration of corticosteroid use was longer in patients receiving azathioprine (232 vs. 168 days; P G 0.005). Median maintenance of first remission in patients who initially used corticosteroids, however, was longer in patients receiving azathioprine compared with nonazathioprine patients (PCDAI, 544 vs. 254 days, P = 0.08; corticosteroid free, 575 vs. 259 days, P G 0.05, respectively). We conclude that, since 2000, azathioprine is being introduced earlier in the treatment of newly diagnosed pediatric CD patients. The use of azathioprine is associated with prolonged maintenance of the first remission.

NASPGHAN Clinical Report on the Evaluation and Treatment of Pediatric Patients With Internal Penetrating Crohn Disease

“…Pediatric studies have shown the efficacy of immunomodulators (6-mercaptopurine, azathioprine, and methotrexate) in maintaining remission in pediatric CD (33)(34)(35)(36).…”

Two-Year Outcomes After Exclusive Enteral Nutrition Induction Are Superior to Corticosteroids in Pediatric Crohn’s Disease Treated Early with Thiopurines

“…Early commencement of TP, within 6 months of diagnosis, has become widespread practice in both adult and pediatric CD since a seminal RCT in treatment naïve children with CD demonstrated a greater steroid-free remission in those commenced on early thiopurines [8]. Recent retrospective pediatric studies have reported much lower efficacy of TP in maintaining remission in pediatric CD [9][10][11][12].…”

Time to Relapse in Children with Crohn’s Disease Treated with Azathioprine and Nutritional Therapy or Corticosteroids

“…In studies without early IMM use, the remission rates seemed to be higher when EEN was used as induction treatment (Fig. 4 in ''Appendix,'' column 2, 3) [15,32,33]. Contrary to CS, positive impact of EEN on mucosal healing may potentially increase durability of remission [6,9].…”

“…Several recently published studies comparing long-term outcomes of EEN and CS have assessed and compared rates of remission between groups (Fig. 4 in ''Appendix'') [15][16][17][18][19][32][33][34][35].…”

“…4. [15], the current study, Jaspers et al [31], Lambert et al [19], and Riello et al [33]), two prospective studies (the GROWTH study [18], and the study by Puanti et al [32]), and a randomized controlled trial by Markowitz et al [34] were included in the analysis. The PCDAI score at diagnosis varied in the majority of studies from 30 to 40; a higher PCDAI was reported in the studies by Riello et al [33] and Markowitz et al [34] …”