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P574 The efficacy of azathioprine and tumour necrosis factor antagonists in preventing Crohn's Disease recurrence after ileal resection: a tertiary center real-life experience

M. Allocca*1, G. Fiorino1, M. Alfieri1, P. Turri1, M. Delliponti1, D. Gilardi1, I. Bravatà2, M. Sacchi3, A. Spinelli3, A. Repici2, S. Danese1

1Humanitas Research Hospital, IBD Center, Gastroenterology, Rozzano, Milan, Italy, 2Humanitas Research Hospital, Endoscopy Unit, Gastroenterology, Rozzano, Milan, Italy, 3Humanitas Research Hospital, IBD Surgery, Colo-rectal Surgery, Rozzano, Milan, Italy

Background

About one-third of Crohn's disease (CD) patients will undergo abdominal surgery within the first 5 years after diagnosis. However, more than 70% of these patients will develop endoscopic recurrence by the end of the first year after surgery. Both azathioprine and anti-tumor necrosis factor agents (anti-TNFs) have shown efficacy in preventing post-operative recurrence of CD, but there are limited data comparing different preventive strategies in real-life.

Methods

103 CD patients, followed-up in a tertiary IBD Center, that underwent ileal resection with ileocolonic anastomosis between January 2007 and October 2014, were enrolled. All subjects were given preventive therapy after a median time of 1 month (range 0.2-9.2) with anti-TNFs (infliximab or adalimumab), thiopurines (azathioprine/6-MP) or mesalazine (controls), according to the risk of early recurrence. The primary outcome was to assess the rate of endoscopic recurrence (defined by Rutgeerts score (Rs) >2) within a maximum of 24 months (median 8.2 months). Statistical analysis included logistic regression with univariate analysis for risk factors and Fisher exact test for variance. All differences were considered statistically significant for p<0.05.

Results

Among the study population, 24 patients (23.3%) received anti TNF (16 infliximab; 8 adalimumab), 43 (41.7%) received thiopurines, 36 (34.9%) received a mean dose of mesalazine 3 g/day. The presence of 2 or more risk factors (smoking, prior intestinal surgery, penetrating disease behavior, perianal disease) was not associated with a higher risk of endoscopic recurrence (OR 1.53; 95% CI 0.99 to 237; p=0.05), but multivariate analysis showed that only the active smokers were more likely to have endoscopic recurrence (OR 3.09; CI 95% 1.14 to 8.34; p=0.02). Endoscopic recurrence rate was significantly lower in subjects receiving anti-TNFs and thiopurines compared to mesalazine (33.3% vs 66.6%, p=0.017; 41.8% vs 66.6%, p 0.04, respectively). Finally, anti-TNFs and thiopurines were not effective in the prevention of severe recurrence (defined by Rs 3-4). Escalation therapy was performed in 18 patients (28% from mesalazine to anti-TNFs ( group A); 22% increased the dose of anti-TNFs ( group B); 33% from mesalazine to thiopurines (group C); 17% from thiopurines to anti-TNFs (group D). 50% of them had an improvement of endoscopic recurrence (60%, 25%, 50%, and 33%, respectively), after a median time of 16 months.

Conclusion

Both anti-TNFs and thiopurines were effective in the prevention of endoscopic recurrence compared to mesalazine. No differences were found between anti-TNFs and thiopurines. Escalation therapy improved mucosal lesions in 50% of patients.