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Rise of anti-TNF means less resections in pediatric IBD
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Since anti-TNF alpha therapy for inflammatory bowel disease was introduced, there has been a significant drop in surgical resections in pediatric patients, according to research published in Alimentary Pharmacology & Therapeutics.
Robert Mark Beattie, FRCPCH, MRCP, MBBS, BSc, of the department of pediatric gastroenterology at Southampton Children’s Hospital in the United Kingdom, and colleagues wrote that there has been a rapid increase in the use of anti-TNF over the last 15 years resulting in better symptom control and intestinal healing among patients.
“The longterm impact of anti-TNF medications on the rates of surgery before transition to adult services in pediatric IBD is uncertain,” they wrote. “Previous data appear to suggest that anti-TNF therapy delays but not avoids the need for surgery in childhood.”
Researchers analyzed data from patients diagnosed with pediatric IBD in the Wessex region of the U.K. between 1997 and 2017 (n = 825; Crohn’s disease, n = 498; ulcerative colitis, n = 272; unclassified IBD, n = 55). They explored the prevalence of anti-TNF therapy and yearly surgery rates during childhood (younger than 18 years).
Over the course of 20 years, the prevalence of anti-TNF treated patients increased from 5.1% to 27.1% (P = .0001). During that same period, the surgical resection rate in patients with pediatric IBD decreased from 7.1% to 1.5% (P = .001), driven by a decrease in CD resections (8.9% to 2.3%; P = .001). Rates for perianal surgery and UC-related resection went unchanged.
Although the mean age at resection did not change, time from diagnosis to resection increased (1.6 to 2.8 years; P = .028), and patients that had to undergo resection were diagnosed at a younger age in the five most recent years of the analysis (2007-2011 = 13.1 years; 2013-2017 = 11.9 years; P = .014).
“These data suggest that anti-TNF therapy may be modifying the natural history of IBD in childhood,” Ashton and colleagues wrote. “Progression to personalizing therapy within pediatric IBD now appears to be the next major challenge, balancing which patients would benefit from early introduction of anti-TNF therapy and those where an expectant approach can be adopted.” – by Alex Young
Disclosures: The authors report no relevant financial disclosures.
Perspective
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Aline Charabaty, MD
Crohn’s disease is a chronic inflammatory bowel disease that often affects the very young with a peak age of onset between 15 to 25 years. Although it commonly presents with inflammatory manifestations, Crohn’s disease is a progressive disease that can lead to stricturing and/or perforating complications, such as bowel obstruction, bowel perforation, intra-abdominal abscesses, and perianal disease. Up to one-third of pediatric Crohn’s patients will undergo a disease related surgery during childhood, before transitioning to adult care. The introduction of anti-TNF drugs in our therapeutic armamentarium has revolutionized how we treat IBD: these drugs are not only effective in rapidly inducing and maintaining clinical remission in patients with IBD but also in achieving mucosal healing. In clinical trials, patients who received anti-TNF early in the course of their disease had a higher response and remission rate compared with those who received this therapy after a long disease duration. The next question becomes, do anti-TNF drugs and early introduction of anti-TNF therapy after diagnosis, affect the natural history of Crohn’s disease, ie, decrease the rate of complications and surgeries.
This study shows that anti-TNF therapy was associated with a reduced rate of surgeries in the pediatric Crohn’s population, even more so when it was initiated early in the disease course. Further, anti-TNF use was associated with a delay in surgery from the time of diagnosis.
These data highlight the importance of initiating anti-TNF therapy early during disease in children with moderate to severe Crohn’s disease, and in those at higher risk for complications (such as small bowel disease) to control the inflammation early and effectively, before irreversible structural damage occurs, and complications requiring surgery ensue. In other words, anti-TNF should not be delayed until complications occur in the pediatric population. Parents and physicians can be hesitant in initiating anti-TNF drugs in young children with a recent diagnosis of Crohn’s disease, raising the concern for potential risks for these long-term therapies. In light of this study, the decrease in surgical rate with anti-TNF therapy should be part of the risks and benefits discussion treating physicians have with parents of children with Crohn’s disease. It is important to remember, that by avoiding surgery (or even by delaying surgery beyond childhood), we are also avoiding the associated hospitalizations, potential complications, days away from home, school, friends and “normal life”, body image issues, all things that can add to the physical and emotional (and financial) burden the disease has on children and their families.
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