Exposure to advanced therapies and risk of surgery in Crohn’s disease

Background & aims: While advancements in therapeutic options for inflammatory bowel disease reduced rates of surgical resection, some patients still require surgery despite multiple lines of medical therapies. This study investigates the relationship between the number, class, and progression rate of different advanced therapies (AT) and risk of surgical resection and postoperative complications in patients with Crohn’s Disease (CD). Methods: This study is a retrospective cohort study utilizing the MarketScan database, including adult patients with CD on AT from 2005 to 2020. The number of AT, class of AT, and comorbidities were assessed for all patients. The primary endpoint was surgical resection. A time-varying Cox proportional hazards regression model was used to assess risk of surgical resection. Logistic regression was used to assess secondary outcomes, including postoperative complications, readmissions, and emergency department (ED) visits. Results: The sample included 15,547 patients of whom 10.6% required surgical resection at some point. Use of anti-integrin therapy as first line was associated with higher risk of surgery compared to TNF-alpha inhibitors (Hazard ratio [HR] 1.39, p < 0.05). Utilization of 2, 3, or ≥ 4 AT was associated with increased surgery risk (HRs of 2.80, 4.54, and 7.82, respectively, p < 0.001). The number and class of ATs were not associated with postoperative complications, readmissions, or ED visits. Conclusion: Use of first-line anti-integrin was associated with higher risk of surgery and thus our study supports the use of TNF-alpha inhibitors as the first-line therapy in treatment-naïve patients. Nevertheless, multidisciplinary care is crucial in identifying and counseling patients at risk of surgery.