DOP045 Combination therapy with anti-TNF and immunosuppressive therapies is the most effective medication to prevent and treat endoscopic postoperative recurrence in patients with Crohn’s disease

Abstract

Background: Anti-TNF agents are considered the most effective medications to prevent and to treat endoscopic postoperative recurrence (POR) in Crohn's disease (CD). We assessed the impact of prior anti-TNF exposure, prior primary non-response to anti-TNF before surgery and concomitant use of immunosuppressive therapy on the efficacy of anti-TNF to prevent endoscopic or clinical POR. Methods: From a prospectively maintained database, we consecutively enrolled all patients with CD who underwent intestinal resection between 2011 and 2016 with colonoscopy at 6 months (6m) and follow-up >6 months. Endoscopic POR was defined as Rutgeerts' Index ≥ i2. Clinical POR was defined as recurrence of symptoms (HBI>4) leading to hospitalisation or therapeutic intensification after exclusion of other causes of recurrent symptoms. Multivariate analyses were performed including all the potential risk factors. Results: In anti-TNF-naive patients (n = 117 patients), anti-TNF monotherapy was more effective than other medications in preventing endoscopic POR (8.7% vs. 37.2%, p = 0.011). In multivariate analysis, anti-TNF therapy was the most effective medication to prevent endoscopic POR (OR=0.145 [0.029-0.714], p = 0.018). In patients with prior exposure to anti-TNF agents before the surgery (n = 199 patients), resuming the same anti-TNF agent than before the surgery was not associated with higher risk of endoscopic POR (43.5% vs. 33.6%, p = 0.188) even in the case of primary non-response with this specific anti-TNF (40.4% vs. 27.3%, p = 0.175). Anti-TNF monotherapy was not associated with a significant decreased risk of endoscopic POR (34.4% vs. 44.6%, p = 0.175). In contrast, combination therapy with anti-TNF and immunosuppressive therapy was associated with lower rate of endoscopic POR (28.4% vs. 43.2%, p = 0.046). In multivariate analysis, combination therapy was the only treatment that was a protective factor of endoscopic POR (OR=0.477 [0.219-0.997], p = 0.041) and prior exposure to more than two anti-TNF prior surgery was associated with higher risk of endoscopic POR (OR=4.17 [1.56-11.15], p = 0.004). In patients not on anti-TNF who had endoscopic POR at 6 months (n = 75 patients), combination therapy was more effective than the other medications (p = 0.03). In multivariate analysis, combination therapy (HR=0.379 [0.14-0.99], p = 0.049) was a protective factor of clinical POR, while prior exposure to more than two anti-TNF prior surgery was associated with higher risk of endoscopic POR (OR=4.34 [1.24-15.23], p = 0.022). Conclusions: Anti-TNF agents are the most effective therapy to prevent and to treat endoscopic POR in CD. Concomitant use of immunosuppressive therapy should be preferred in patients with prior exposure to anti-TNF or to treat endoscopic POR.