Change in Biologic Class Promotes Endoscopic Remission Following Endoscopic Postoperative Crohn's Disease Recurrence

Salam P Bachour; Ravi S Shah; Abel Joseph; Hareem Syed; Adel Hajj Ali; Florian Rieder; Edward L Barnes; Jordan Axelrad; Stefan D Holubar; Miguel Regueiro; Benjamin L Cohen; Benjamin H Click

doi:10.1097/MCG.0000000000001943

Change in Biologic Class Promotes Endoscopic Remission Following Endoscopic Postoperative Crohn's Disease Recurrence

J Clin Gastroenterol. 2023 Nov 27. doi: 10.1097/MCG.0000000000001943. Online ahead of print.

Authors

Salam P Bachour^{1

2}, Ravi S Shah³, Abel Joseph⁴, Hareem Syed⁴, Adel Hajj Ali⁵, Florian Rieder^{3

6}, Edward L Barnes⁷, Jordan Axelrad⁸, Stefan D Holubar⁹, Miguel Regueiro³, Benjamin L Cohen³, Benjamin H Click^{3

9}

Affiliations

¹ Cleveland Clinic Lerner College of Medicine.
² Department of Medicine, Brigham and Women's Hospital, Boston, MA.
³ Department of Gastroenterology, Hepatology, and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic.
⁴ Department of Internal Medicine, Cleveland Clinic.
⁵ Heart, Vascular, and Thoracic Institute, Cleveland Clinic.
⁶ Department of Colorectal Surgery, Cleveland Clinic.
⁷ Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, NC.
⁸ Department of Gastroenterology and Hepatology, New York University, New York, NY.
⁹ Division of Gastroenterology, University of Colorado Anschutz Medical Campus, Aurora, CO.

PMID: 38019054
DOI: 10.1097/MCG.0000000000001943

Abstract

Goals: Assess the outcomes of various therapeutic regimens to treat initial endoscopic postoperative recurrence despite biologic prophylaxis.

Background: Postoperative biologic prophylaxis reduces postoperative Crohn's disease (CD) recurrence rates. Optimal treatment strategies for endoscopic recurrence have not been elucidated.

Study: Retrospective cohort study of adult CD patients who underwent ileocolonic resection between 2009 and 2020. Patients with endoscopic postoperative recurrence despite prophylactic biologic therapy and ≥1 subsequent colonoscopy were included. Treatment changes after recurrence were categorized as (1) therapy optimization or continuation or (2) new biologic class. The primary outcome was composite endoscopic or surgical recurrence at the time of or prior to subsequent follow-up colonoscopy.

Results: Eighty-one CD patients with endoscopic recurrence (54.3% i2b, 22.2% i3, and 23.5% i4) despite biologic prophylaxis (86.4% anti-tumor necrosis factor, 8.6% vedolizumab, 4.9% ustekinumab) were included. Most patients received therapy optimization or continuation (76.3%, n=61) following recurrence compared to being started on a new biologic class. Sixty patients (N=48 therapy optimization; N=12 new biologic class) experienced composite recurrence (78.3% endoscopic, 21.7% surgical). On multivariable modeling, initiation of a new biologic class was associated with reduced risk for composite recurrence compared to therapy optimization or continuation (aOR: 0.26; P=0.04). Additionally, initiation of a new biologic class was associated with endoscopic improvement when adjusting for endoscopic severity at the time of recurrence (aOR: 3.4; P=0.05). On sensitivity analysis, a new biologic class was associated or trended with improved rates of endoscopic healing and composite recurrence when directly compared to therapy optimization or continuation.

Conclusion: In patients with CD who experience endoscopic recurrence despite biologic prophylaxis, changing the mechanism of biologic action may promote endoscopic improvement.

Abstract

Grants and funding