Surgery risk for IBD declining in biologic era, ‘but that doesn’t mean it’s zero’
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Although the rate of surgery for inflammatory bowel disease has declined significantly in the era of biologic therapy, “it is still occurring,” according to a presenter at the Crohn’s and Colitis Congress.
“If you think in terms of risk, about what the most disabling situation is when it comes to ulcerative colitis, it’s probably surgery, and most patients would like to avoid this at any cost,” Angelina Collins, MSN, ANP‐BC, from the Inflammatory Bowel Disease Center at UC San Diego Health, told attendees. “There is hope that the amount of surgery happening for ulcerative colitis patients is declining in the biologic era, but that doesn’t mean it’s zero.”
Data published in Clinical Gastroenterology and Hepatology by Tsai and colleagues reported that the 10-year risk for surgery for ulcerative colitis dropped from 15% in the years prior to 2000 to 9.6% in the years after biologic therapies were introduced.
“So, there is still a 10% risk of a patient going to colectomy after 10 years of having the disease,” Collins said. “The question comes: What can we do early on in the disease course to potentially prevent that from happening? Thinking in terms of risk is important because we need to get early control of inflammation, which is going to yield a more stable disease course over time and fewer complications and disability.”
Patients with ulcerative colitis at high risk for colectomy include those diagnosed prior to age 40 years, those with anatomic involvement, large and/or deep ulcers on endoscopy, those with disease requiring early use of steroids, elevated CRP and/or ESR, Clostridium difficile or cytomegalovirus infection and prior hospitalization for ulcerative colitis.
“Many of these we can see even without talking to the patient,” Collins noted. “We already have a sense on how many of these high-risk features a patient has when we see them.”
Similarly, she reported that “some pretty nice headway” has been made in surgery rates for patients with Crohn’s disease, with a decline in 10-year risk of surgery from 46.5% to 26.2% after biologic therapies were introduced.
“We are used to thinking of Crohn’s disease as a progressive disease, with 10 to 25% of patients expected to develop perianal disease by 20 years,” Collins said. “In the past, we thought 70 to 80% of patients were going to have surgery at some point during their lifetime.”
Patients with CD considered high-risk for progression and complications include those diagnosed prior to age 30 years, those with extensive anatomic involvement or large and deep ulcers, structuring disease, penetrating disease and prior surgeries or resections. In addition, severe rectal disease is “also a significant complication because, worst case scenario, this is going to lead to conversion of their rectum and that has devastating consequences long-term,” Collins noted.
In conversations with patients, Collins recommended that providers frame risk as an implication for disease progression, surgery, reduced response to therapy and complication.
“What are the risks of progressive disease? What is the risk of flaring again? It increases our need for steroids, complications of disease in general and increases risk for surgery,” she said. “When we do talk about medications, it is not just the risk of a particular medication or one medication over another. We have to incorporate this [into a discussion with our patients] that says what happens if we don’t treat the disease or if we don’t monitor the disease. What is this going to lead to?”
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Collins A, et al. Assessing risk in IBD and early treatment intervention. Presented at: Crohn’s and Colitis Congress (virtual); Jan. 20-22, 2022.
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