The long-term effect on surgery-free survival of biological compared to conventional therapy in Crohn’s disease in real world-data: a propensity-score matched study

Abstract

BACKGROUND: The introduction of biological drugs has led to great expectations and growing optimism in the possibility that this new therapeutic strategy could favourably change the natural history of Inflammatory Bowel Disease (IBD) and in particular that it could lead to a significant reduction in surgery in the short and long term. The evaluation of the incidence of intestinal resection after the introduction of biological therapy is very complex and subject to several potential bias, the most prominent being the shift in IBD management over the last few decades. This study aims to assess the impact of biological versus conventional therapy on surgery-free survival time (from the diagnosis to the first bowel resection) and on the overall risk of surgery in patients with Crohn’s disease (CD) who were never with the surgical option. METHODS: This is a retrospective, double-arm study including CD patients treated with either biological or conventional therapy (mesalamine, immunomodulators, antibiotics, or steroids). All CD patients admitted at the GI Unit of the S. Salvatore Hospital (L’Aquila. Italy) and treated with biological therapy since 1998 were included in the biological arm. Data concerning the CD patients receiving a conventional therapy were retrospectively collected from our database. These patients were divided into a pre-1998 and post-1998 group. Our primary outcome was the evaluation of the surgery-free survival since CD diagnosis to the first bowel resection. Surgery-free time and event incidence rates were calculated and compared among all groups, both in the original population and in the propensity-matched population. RESULTS: 203 CD patients (49 biological, 93 conventional post-1998, 61 conventional pre-1998) were included in the study. Kaplan-Mayer survivorship estimate shows that patients in the biological arm had a longer surgery-free survival compared to those in the conventional arm (p=0.03). However, after propensity matching analysis, no significant difference was found in surgery-free survival (p=0.3). A sub-group analysis showed shorter surgery-free survival in patients on conventional therapy in the pre-biologic era only (p=0.02) while no significative difference was found between the biologic and conventional post-biologic groups (p=0.15). CONCLUSION: This study shows that the introduction of biological therapy had only a slight impact on the occurrence of surgery in CD patients over a long observation period. Nevertheless, biological therapy appears to delay the first intestinal resection.