Improving long-term outcomes of Crohn's disease

Last Updated: 2016-12-23

By Will Boggs MD

NEW YORK (Reuters Health) - Changes in the medical management of Crohn's disease over the past two decades have been paralleled by improvements in long-term outcomes, researchers from The Netherlands report.

Numerous clinical trials have demonstrated the efficacy of immunomodulators and anti-TNF-alpha agents in inducing and maintaining disease remission in patients with Crohn's disease (CD), but it remains unclear whether these treatments have resulted in improved long-term outcomes.

Dr. Steven F. G. Jeuring from Maastricht University Medical Center and colleagues used data from the Inflammatory Bowel Disease South Limburg cohort (1,162 patients) to evaluate changes in the medical management and long-term outcomes of CD between 1991 and 2014.

There were 316 patients from the 1991-1998 "pre-biological" era, 387 patients from the 1999-2005 "early biological" era, and 459 patients from the "late biological" era, according to the December 6th online report in The American Journal of Gastroenterology.

Immunomodulator treatment increased from 30.6% in 1991-1998 to 56.7% in 1999-2005 and 70.8% in 2006-2011, while anti-TNF-alpha exposure increased from 3.1% to 19.9% to 41.2%, respectively.

The number of patients with complicated disease at diagnosis decreased significantly from era to era, but there were no changes over time in the progression rate.

The cumulative five-year probability of hospitalization decreased from 65.9% in the earliest era to 44.2% in the latest era, and the median number of days admitted per hospitalization decreased from 14.5 to 8.0.

Similarly, the cumulative five-year probability of surgery decreased from 42.9% to 17.4% over this two-decade interval, while cumulative corticosteroid use (in terms of days and dosage) decreased over time.

These improvements were not significantly related to the use of immunomodulators or anti-TNF-alpha treatment, the authors report.

"Future studies should address whether novel treatment strategies, such as treat to target, can further improve the long-term outcome, in particular the risk of developing structural bowel damage," they conclude.

Dr. Edward L. Barnes from the University of North Carolina School of Medicine in Chapel Hill, who has researched Crohn's disease extensively, told Reuters Health by email, "In my opinion, the most interesting findings are the decrease in hospitalization and surgery rates over the three time periods examined. These findings would seem to indicate that we have improved our overall approach to the management of patients with Crohn's disease."

"Despite these improvements, the lack of ability to affect the natural history or progression of Crohn's disease with medications such as immunomodulators and anti-TNF therapies is also striking, despite using these therapies more frequently and earlier in the disease course (closer to the time of diagnosis)," he said.

"I think it is important to note that changing the clinical symptoms that a patient experiences will not necessarily change the natural history of Crohn's disease," Dr. Barnes said. "To this end, there has been increased emphasis on treat to target strategies, for example strategies focused on mucosal healing, which may be better equipped to accomplish the goal of changing the natural history of the disease. Focusing on mucosal healing and endoscopic/histologic remission in addition to clinical remission based on symptoms may lead to a more complete remission, which potentially could have a greater effect on the progression of Crohn's disease."

Dr. Jeuring did not respond to a request for comments.

SOURCE: http://go.nature.com/2gNazGt

Am J Gastroenterol 2016.