Changes in medical treatment and surgery rates in inflammatory bowel disease: a nationwide cohort study 1979–2011

Abstract

Introduction Treatment possibilities have changed in inflammatory bowel disease (IBD). We assessed changes in medical treatment and surgery over time and impact of medications on risk of surgery in a population-based cohort. Methods 48 967 individuals were diagnosed with IBD (Crohn's disease (CD), 13 185; ulcerative colitis (UC), 35 782) during 1979–2011. Cumulative probability of receiving 5-aminosalicylic acids (5-ASA), topical, oral corticosteroids, thiopurines, and tumour necrosis factor-α (TNF-α) blockers, and of first minor or major surgery according to period of diagnosis, was estimated. Medication use and risk of surgery was examined by Cox regression. Results 5-year cumulative probability of first major surgery decreased from 44.7% in cohort (1979–1986) to 19.6% in cohort (2003–2011) (p < 0.001) for CD, and from 11.7% in cohort (1979–1986) to 7.5% in cohort (2003–2011) (p < 0.001) for UC. Minor surgery risk decreased significantly in CD. From cohort (1995–2002) to cohort (2003–2011), a significant increase in use of thiopurines and TNF-α blockers was observed, paralleled by a significant decrease in use of 5-ASA and corticosteroids. Comparing use of azathioprine (or oral corticosteroids) to never-use, no convincing surgery-sparing effect was found. Comparing use in 3+ months of a given drug with use <3 months, only 3+ months use of oral corticosteroids reduced the risk of surgery in patients with disease duration of >1 year. Conclusions Parallel to an increasing use of thiopurines and TNF-α blockers in IBD over time, a persistent significant decrease in surgery rates was observed along with a significant decrease in use of 5-ASA and corticosteroids. However, no convincing surgery-sparing effect of newer medications was found.

The changing face of Crohn’s disease: a population-based study of the natural history of Crohn’s disease in Örebro, Sweden 1963–2005

“…To reduce the risk of bias, due to the introduction of these novel techniques in different years, upper gastrointestinal disease (L4) was regarded were 2.0% and 8.4% at 1 and 5 years, respectively, from diagnosis and are lower than in some earlier reports from referral centres. However, the time period represents the early years within the era of biologics, when the treatment strategies were yet to be established and biologics often introduced late during the disease course as a third-line treatment, and other population-based studies from these years have revealed similar figures (2,5,7,8). Therefore, the study was not designed to address the question of disease modification due to anti-TNF therapy.…”

“…Medical therapy advanced with the use of immunomodulators and the introduction of biologics. Changes in medical therapy and surgical practice over time might have influenced the natural history of the disease and possibly reduced surgery rates (1)(2)(3)(4)(5)(6)(7). However, epidemiological studies that have evaluated the effect of immunomodulators on surgery rates have yielded conflicting results (7)(8)(9).…”

Long-term evolution and predictive factors of mild inflammatory bowel disease

“…Although similar, our results cannot be strictly compared with those from the IBSEN study because this is not a population-based study but a monocentre retrospective cohort. The population-based cohort of Rungoe et al [21] demonstrated a decreased probability rate of surgery at 5 years in CD and UC in the last 10 years but without a surgery-sparing effect of newer medications. Due to the retrospective character of the study, the type of resection was not taken into account.…”

Inflammatory bowel disease in pregnancy: a population‐based study of prevalence and pregnancy outcomes

“…Rates of surgery for IBD have been reported to be decreasing. 5,6 Studies have also shown that women with active disease or previous abdominal surgery had reduced pregnancy rates. [7][8][9] A population-based study from Sweden showed that women with IBD had twice the rate of caesarean section compared with control women, and that women with UC had increased rates of venous thromboembolism (VTE).…”