Crohn's: Cochrane review unclear on best way to maintain remission after surgery

  • Iheozor-Ejiofor Z & al.
  • Cochrane Database Syst Rev
  • 12 sept. 2019

  • de Craig Hicks
  • Clinical Essentials
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Takeaway

  • Not enough evidence is available to conclude which treatment is most effective for preventing recurrence of Crohn’s disease (CD) after surgery.

Why this matters

  • About three-quarters of patients with CD undergo surgery to induce remission, but 20%-86% experience clinical relapse within 5 years.

Study design

  • Researchers conducted a network meta-analysis of 26 randomized controlled trials (n=2581) comparing interventions for maintaining surgically induced CD remission.
  • Interventions included 5‐aminosalicylic acid (5‐ASA), adalimumab, antibiotics, budesonide, infliximab, probiotics, purine analogues, sulfasalazine, and a combination of sulfasalazine and prednisolone.
  • Funding: Crohn's and Colitis Canada; UK National Institute for Health Research.

Key results

  • Only 5 interventions appeared to prevent clinical relapse:
    • Adalimumab (HR, 0.11; 95% credible interval [Crl], 0.02-0.33; low‐certainty evidence);
    • 5‐ASA (HR, 0.69; 95% Crl, 0.53-0.87; moderate‐certainty evidence);
    • Budesonide (HR, 0.66; 95% CrI, 0.27-1.34; low‐certainty evidence);
    • Infliximab (HR, 0.36; 95% CrI, 0.02-1.74; very-low‐certainty evidence); and
    • Purine analogues (HR, 0.75; 95% CrI, 0.55-1.00; low‐certainty evidence).
  • No intervention appeared to be effective for preventing endoscopic relapse other than adalimumab (HR, 0.10; 95% CrI, 0.01-0.32; low‐certainty evidence).

Limitations

  • Overall certainty of the evidence was low to very low.
  • Most studies had high risk of bias, small sample sizes, and imprecise outcome reporting.