Early immunotherapy doesn’t prevent surgery in kids with Crohn’s disease

Note from Grupo De Apoyo EII: Not all children with Crohn’s disease will need surgery.
NEW YORK (Reuters Health) – Starting immunomodulator therapy as soon as children are diagnosed with Crohn’s disease (CD) doesn’t change the chances that they’ll need bowel surgery within 5 years, analysis of registry data suggests.

However, older age at diagnosis, greater CD severity, and strictures or penetrating disease do predict a higher risk for CD surgery in kids, while distal disease appears to be protective, the authors report in the September issue of Clinical Gastroenterology and Hepatology.

The Pediatric Inflammatory Bowel Disease Collaborative Research Group, led by Dr. Neil LeLeiko at Hasbro Children’s Hospital in Providence, Rhode Island, followed 855 children starting within 30 days of their CD diagnosis. Forty-two were between the ages of 0 and 5 years, 481 between 6 and 12 years, and 331 between 13 and 16 at enrollment. The mean follow-up was 2.3 years (range 0 to 6.5 years).

Rates of bowel surgery (intestinal resection with primary anastomosis or ostomy, strictureplasty, or appendectomy) within 5 years of diagnosis were 2.9% in the lowest age-group, 9.9% in those ages 6-12, and 21.5% for those aged 13 to 16.

Overall, the cumulative incidence at 5 years was 13.8% for bowel surgery and 4.5% for non-bowel surgery (abdominal, perirectal or labial abscess drainage or fistulotomy).

The authors note that the 5-year risk of bowel surgery in this study was lower than in other pediatric cohorts: 47.2% in a study published in 1997, 17% in a group managed between1979 and 2003, and 34% in patients diagnosed between 1988 and 2002. They suggest this might be because the current study enrolled an inception cohort, thereby including “many patients destined to do well who might be more readily missed by other study designs.”

Within a month after diagnosis, 70% of the children had started on prednisone, 61% had started mesalamine, and 44% had started taking immunomodulators. By one year, more than 80% were on immunomodulating therapy. But none of the medications used – mesalamine, corticosteroid, or infliximab – significantly affected the 5-year risk of bowel surgery.

On multivariate analysis, independent predictors of bowel surgery were older age at diagnosis (hazard ratio 1.1, p = 0.042), disease severity according to physician global assessment (HR 2.6, p < 0.0001), stricturing disease (HR 6.6, p < 0.0001), and penetrating disease (HR 3.7, p = 0.0005).

Disease present between the transverse colon and rectum lowered the risk (HR 0.4, p = 0.007).
On the other hand, gender, race, family history of inflammatory bowel disease, and calendar year of diagnosis (2002 through 2008) did not influence the likelihood of bowel surgery.

The investigators note that their cohort comes mainly from the east and midwest regions of the U.S. and eastern Canada, and therefore may not represent all childhood CD.

They conclude that because of limitations of their study design, “the effects of specific medications on surgical rates are speculative. Treatments focused on early intervention will need to be assessed in studies that involve randomized controlled trials.”

SOURCE: http://link.reuters.com/kub88n