Long term outcome of top-down therapy in Crohnʼs disease: A single-center experience

Abstract

Background & AIMS: Crohn's disease (CD) is an idiopathic chronic inflammatory disorderof the gastrointestinal tract and has been conventionally managed by the traditionalstep-up therapy. Several trials have shown that early treatment of CD with anti-TNF agents, top- down therapy, leads to superior clinical outcome including mucosalhealing and reduction in hospitalization and surgery. However, we are still uncertainabout the long-term effectiveness and safety. Furthermore the prognosis of CDpatients who withdrew the top-down therapy is unknown. The aim of this study is toevaluate the efficacy and safety of top-down therapy, and to clarify the outcome of CDpatients who have ceased anti-TNF treatment after the top-down therapy. Methods: We performed a retrospective cohort study in single center. All eligiblepatients had an established diagnosis of CD, and were injected first infliximab within 2years after diagnosis as top-down therapy. Patients with history of use of immunomodulatorsand/ or corticosteroids and resection of their intestine were excluded. Results: 66 (approximately 7 percent) patients with CD in our hospital receivedtop-down therapy. 97.0 percent of them had a clinical response after 3 times ofinfliximab injections, and 71.3 percent of patients had clinical remission for oneyear and 51.5 percent of patients for three years. 72.1 percent of patients treatedwith top-down therapy achieved endoscopic "mucosal healing". Among thesepatients, 58.1 percent of patients tried to cease anti-TNF treatment and the rest ofthem sustained it. Half of the patients who ceased anti-TNF treatment were able tokeep clinical remission (Group A) for about three years, but the other half encountereddisease flare in their clinical course (Group B) and needed to resume anti-TNFtreatment. Age of disease onset (25.3+-13.3) of group A was higher than that(20.9+-4.8) of group B (P<0.01), and the disease period before the diagnosis(47.6+-17.9 months) in group A was shorter than that (66.6+-8.6 months) in groupB. 33.3 percent of patients in group B had intestinal strictures at diagnosis, butnone had them in group A. Duration of anti-TNF treatment before cessation(66.8+-35.4 weeks) in group A was longer than that (19.1+-18.3 weeks) in group B. Conclusions: Cessation of infliximab was successful in 50 percent of thepatients who had mucosal healing after top-down therapy. Factors associatedwith successful cessation were age of disease onset, duration of anti-TNF treatmentand absence of intestinal stricture.