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DOP045. Predicting undesirable disease in newly diagnosed IBD patients - results from the Delta cohort

V. Nuij1, G. Fuhler1, C. Looman2, R. Beukers3, R. Ouwendijk4, M. Rijk5, A. van Tilburg6, R. Quispel7, K. Bruin8, T. Tang9, H. Smalbraak10, F. Lindenburg11, L. Peyrin-Biroulet12, C.J. van der Woude1, 1ErasmusMC University Medical Center, Gastroenterology and Hepatology, Rotterdam, Netherlands, 2ErasmusMC University Medical Center, Public Health, Rotterdam, Netherlands, 3Albert Schweitzer Hospital, Gastroenterology and Hepatology, Rotterdam, Netherlands, 4Ikazia Hospital, Gastroenterology and Hepatology, Rotterdam, Netherlands, 5Amphia Hospital, Gastroenterology and Hepatology, Breda, Netherlands, 6Sint Franciscus Gasthuis, Gastroenterology and Hepatology, Rotterdam, Netherlands, 7Reinier de Graaf Gasthuis, Gastroenterology and Hepatology, Rotterdam, Netherlands, 8Tweesteden Hospital, Gastroenterology and Hepatology, Tilburg, Netherlands, 9IJsselland Hospital, Gastroenterology and Hepatology, Capelle aan den IJssel, Netherlands, 10Lievensberg Hospital, Internal Medicine, Bergen op Zoom, Netherlands, 11Franciscus Hospital, Gastroenterology and Hepatology, Roosendaal, Netherlands, 12Nancy University Hospital, Université de Lorraine, Gastroenterology and Hepatology, Vandoeuvre-les-Nancy, France

Background

In patients with inflammatory bowel disease there is increasing evidence that timely initiation of potent immunosuppressive therapies leads to a less adverse disease course. This could be especially beneficial for patients with more severe disease course. However, upon first presentation, prediction of future disease course is difficult. The aim of the current study was to define predictors for undesirable disease outcome at diagnosis in a population based cohort in the anti-TNF era.

Methods

IBD patients from the Delta cohort, newly diagnosed in 2006, were included. Patient and disease characteristics were obtained from the patients' medical records. Logistic regression analysis and cox-regression analysis were used to assess factors associated with an undesirable disease outcome as determined by previously published criteria and by the Delta Criteria (DC). The DC were defined as having fistula and/or abscesses, major extra-intestinal manifestations (EIM), hospitalization, IBD-related surgery and progression of disease according to Montreal classification during follow-up.

Results

In total, 413 IBD patients were included, (201 CD, 188 UC, and 24 IBDU). Previously published adverse disease outcome criteria were tested on this cohort, however, they were not applicable at diagnosis and there was no correlation with these criteria and adverse outcomes such as surgery. We therefore developed a new predicting model based on undesirable disease outcome as determined by the DC criteria, according to which 42% of patients had undesirable disease. In a cox-regression analysis, having CD (HR 2.1, CI 1.5–2.8), age >35 years (OR 0.68, CI 0.51–0.92), endoscopic disease severity at diagnosis (p = 0.002) and histologic disease severity at diagnosis (p = 0.043) were univariately associated with the DC. In a multivariate analysis, histologic disease severity and having CD remained significantly associated with a more disabling subtype. Strikingly, we also observed that treatment initiation correlates with endoscopic disease severity (steroids p = 0.001, immunosuppressants p < 0.0001, anti-TNF p < 0.0001), but not with histological disease severity.

Conclusion

Previously published adverse disease outcome criteria are unfit for determining at diagnosis whether patients will have an undesirable disease outcome. CD, age >35 years, endoscopic and histologic disease severity at diagnosis are valuable predictors for an undesirable disease course. Multivariate analysis suggests that aiming for early deep remission will prevent disease progression and that histologic disease severity should be more central in deciding treatment strategies.