Perianal Crohn Disease Is More Common in Children and Is Associated With Complicated Disease Course Despite Higher Utilization of Biologics

Abstract

Background and Objectives:Both perianal and pediatric-onset Crohn disease (CD) disease are associated with complicated disease course and higher drug utilization. we aimed to explore the differences between pediatric and adult-onset perianal CD and their disease course.Methods:We included all patients with newly diagnosed CD from 2005 to 2019 at two Israeli Health Maintenance Organizations, covering 78% of the population. A combination of ICD-9 codes, radiology and procedures was used to define fistulizing perianal CD (PCD) and its severity according to the association with simple and complex perianal disease.Results:A total of 12,905 patients were included (2186 [17%] pediatric-onset, 10,719 [83%] adults), with a median follow-up of 7.8 years. PCD was diagnosed in 1530 (12%) patients, with higher incidence in children (308 [14%] children vs 1222 adults [11%]; P < 0.001). Children had higher incidence of severe PCD (141/308 [47%] vs 433/1222 [35%]; P < 0.001). At 5 years, children with PCD were more likely than adults to be treated with biologics (212 [69%] vs 515 [42%]; odds ratio [OR] 2.6 [95% confidence interval (CI) 1.6–4.0]; P < 0.001) and immunomodulators (238 [74%] vs 643 [53%]; OR 2.8 [95% CI 2.1–3.6]; P < 0.001). PCD in children was still associated with poorer disease outcomes as shown for surgeries (36 [12%] vs 93 [8%]; P = 0.02) and steroid-dependency (52 [17%] vs 156 [13%]; P < 0.001). Multivariable modeling indicated that the severity of PCD is a stronger predictor of disease course than age.Conclusion:PCD is more common in pediatric-onset CD and is associated with higher drug utilization and worse disease outcomes, in large due to higher rate of severe PCD in children.

Long-term Outcomes of Perianal Fistulas in Pediatric Crohn’s Disease

“…P erianal Crohn's disease affects up to 40% of adults and 9% to 30% of pediatric patients and is associated with worse disease outcomes, including increased hospitalizations and the need for surgery. [1][2][3][4][5][6][7] Perianal fistulizing disease is a severe phenotype of perianal Crohn's disease, affecting 20% to 25% of both adult and pediatric patients. 3,[8][9][10][11][12][13] Perianal fistulizing Crohn's disease is heterogenous and can involve the anus, perineum, or vagina.…”

“…10,42,43 The lower rate of proctectomy may be related to more successful healing rates with local perianal intervention, less duration of disease burden, or differences in treatment strategies for pediatric and adult patients. 7 For example, one large cohort study found that 64% of pediatric Crohn's disease patients received treatment with a biologic, compared to 49% of adult patients. 25 This study also found that increased duration of biologic treatment was associated with a lower need for abdominal surgery in both patient groups.…”

Self-screening questionnaire for perianal fistulizing disease in patients with Crohn’s disease

“…One of the unmet needs in pCD management is the lack of a clinical index that can be easily utilized by patients. Given that pCD is more common in pediatric patients [ 20 ], a simple, child-friendly tool is warranted. In 1992, an anal disease activity index was developed for use in the outpatient clinic or at the patient’s bedside [ 21 ].…”

Clusters of Disease Activity and Early Risk Factors of Clinical Course of Pediatric Crohn’s Disease

“…This is consistent with data highlighting the role of perianal disease at onset as a risk factor for disease progression. [33][34][35] Recently, a systematic review analyzing prognostic risk factors in CD identified small bowel disease location, elevated levels of anti-Saccharomyces cerevisiae antibodies, and polymorphisms in the NOD2/CARD15 genes as prognostic factors of a worse prognosis in pediatric CD. 6 Our research did not include an autoantibodies profile and genetic evaluation because they were unavailable in most patients.…”