The Role of Thiopurines in Reducing the Need for Surgical Resection in Crohn's Disease: A Systematic Review and Meta-Analysis

Chatu, Sukhdev; Subramanian, Venkataraman; Saxena, Sonia; Pollok, Richard

doi:10.1038/ajg.2013.402

Cited by 87 publications

(60 citation statements)

References 38 publications

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“…Immunomodulators are effective maintenance medications and azathioprine has been shown to modestly lower the risk of surgery [23][24][25] . A recent meta-analysis showed a combined pooled HR of 0.59 for first intestinal resection with thiopurine use [26] . Therefore, selecting patients who are most likely to benefit from IM may change the surgical rate of patients with CD.…”

Section: Discussionmentioning

confidence: 99%

Impact of medical therapy on patients with Crohn’s disease requiring surgical resection

Hong

Round

et al. 2014

WJG

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AIM:To evaluate the impact of medical therapy on Crohn's disease patients undergoing their first surgical resection. METHODS:We retrospectively evaluated all patients with Crohn's disease undergoing their first surgical resection between years 1995 to 2000 and 2005 to 2010 at a tertiary academic hospital (St. Paul's Hospital, Vancouver, Canada). Patients were identified from hospital administrative database using the International Classification of Diseases 9 codes. Patients' hospital and available outpatient clinic records were independently reviewed and pertinent data were extracted. We explored relationships among time from disease diagnosis to surgery, patient phenotypes, medication usage, length of small bowel resected, surgical complications, and duration of hospital stay. surgery. Within cohort B, 38 patients (33.3%) received anti-tumor necrosis factor (TNF) agent. No patient in cohort A was exposed to anti-TNF agent. Compared to patients not on anti-TNF agent, ones exposed were younger at diagnosis (anti-TNF vs without anti-TNF: A1/A2/A3 39.5% vs 11.8%, 50% vs 73.7%, 10.5% vs 14.5%, P = 0.003) and had longer median time to surgery (90 mo vs 48 mo, P = 0.02). Combination therapy further extended median time to surgery. Using timedependent multivariate Cox proportional hazard model, patients who were treated with anti-TNF agents had a significantly higher risk to surgery (adjusted hazard ratio 3.57, 95%CI: 1.98-6.44, P < 0.0001) compared to those without while controlling for gender, disease phenotype, smoking status, and immunomodulator use. RESULTS: CONCLUSION:Significant changes in patient phenotypes and medication exposures were observed between the two surgical cohorts separated by a decade.

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Section: Discussionmentioning

confidence: 99%

Impact of medical therapy on patients with Crohn’s disease requiring surgical resection

Hong

Round

et al. 2014

WJG

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“…Finally, a meta-analysis of unselected cohorts focused on the role of thiopurines in need of surgical resection. This analysis revealed that there was approximately 40% reduction in surgery rate in CD patients using thiopurines (HR 0.64, 95% CI 0.44-0.93) [16] .…”

Section: Impact Of Immunomodulatorsmentioning

confidence: 99%

What Can We Learn from Epidemiological Studies in Inflammatory Bowel Disease?

Ďuricová

2017

Dig Dis

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Background: Population-based studies represent the whole spectrum of patient population and should represent the mainstay when evaluating patients' prognosis. A high number of CD patients need surgical intervention during the disease course. The disease course of inflammatory bowel diseases, including ulcerative colitis (UC) and Crohn's disease (CD), is quite varied and still quite unpredictable. Key Messages: According to earlier studies, up to 60% of patients undergo at least one operation after 10 years of CD duration. Newer cohorts report lower cumulative probability of surgery of approximately 40% after 10 years. The colectomy rate in UC is approximately 10% after 10 years from diagnosis with a geographic difference. Similarly to CD, the colectomy rate seems to decrease over time. There is some evidence that the increasing use of immunosuppressive and/or biological therapy might have been responsible for this favourable trend. However, other factors may have an impact on decreasing surgical trend over time. The relative risk (RR) of colorectal cancer (CRC) in UC is approximately doubled compared to background population. However, the absolute risk in general is relatively low between 1.1 and 5.3% after 20 years of disease duration. Furthermore, a decreasing trend in the incidence of CRC has been reported in recent studies. Importantly, several factors such as disease extent, activity, age at UC onset, and so on may increase/modify an individual risk. Similar to UC, CD patients have approximately 2 times higher RR of cancer compared to background population. The risk is higher for colon than for rectum cancer and present only in CD patients with colonic involvement. Conclusions: The surgery rate in CD has decreased over the time period. The evidence on colectomy rate in UC is less conclusive. The RR of CRC in UC and CD is approximately doubled compared to that of the background population, but it seems to be decreasing in more recent cohorts.

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“…Surgery was more common in men aged 17-40 years. Prior intestinal surgery was associated with a marked increase in risk of PAS, whilst neither early steroid use nor smoking was associated with an increased risk PAS [16,27]. These findings reflect a significant burden of perianal disease requiring surgery amongst patient with CD and clinicians need to be aware that a requirement for PAS may often precede the diagnosis of CD by months or years.…”

Section: Main Findingsmentioning

confidence: 90%

Emerging trends and risk factors for perianal surgery in Crohn’s disease: a 20-year national population-based cohort study

Chhaya

Saxena

Cecil

et al. 2016

European Journal of Gastroenterology &Amp; Hepatology

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IntroductionLittle is known about rates of perianal surgery (PAS) in Crohn's disease (CD). Our aim was to determine trends in PAS, the timing of surgery relative to diagnosis of CD and to identify subgroups at risk of PAS. MethodsWe identified 9391 incident cases of CD between 1989-2009. We defined 3 era: era 1 (1989-1995), era 2 (1996-2002), era 3 (2003-2009) and determined trends in procedure type and the time to first PAS relative to the date of diagnosis. We used Kaplan-Meier analysis to demonstrate the rate of first PAS and performed Cox regression to determine subgroups at risk of PAS. ResultsAmong the 9391 incident cases of CD, 405 (4.3%) underwent PAS. The overall rate of PAS was 5.5% (95% CI: 4.9 -6.2%) 10 years after diagnosis. 34% (n=137) of all patients undergoing PAS had surgery in the 5 years before CD diagnosis. Abscess drainage increased from 34% to 58% whilst proctectomy decreased from 16% to 6% between era 1 and 3 respectively. Men (HR 1.51, 95% CI:1.24-1.84), those aged 17-40 years (HR 1.69, 95% CI: 1.09-2.02 vs those aged >40 years) and those with a history of previous intestinal resection (HR: 28.5, 95% CI: 22.2-36.5) were more likely to have PAS. ConclusionAround a third of patients have a PAS 5 years preceding their diagnosis of CD. Surgical practice has changed over twenty years with a decrease in proctectomy and a concurrent increase in abscess drainage. PAS should alert clinicians to consider a possible underlying diagnosis of CD.

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The Role of Thiopurines in Reducing the Need for Surgical Resection in Crohn's Disease: A Systematic Review and Meta-Analysis

Cited by 87 publications

References 38 publications

Impact of medical therapy on patients with Crohn’s disease requiring surgical resection

Impact of medical therapy on patients with Crohn’s disease requiring surgical resection

What Can We Learn from Epidemiological Studies in Inflammatory Bowel Disease?

Emerging trends and risk factors for perianal surgery in Crohn’s disease: a 20-year national population-based cohort study

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