Background: Complications such as need for small bowel resections and hospitalization due to Crohn's disease (CD) occur when disease activity persists due to ineffective therapy. Certain high-risk features require early introduction of anti-TNF therapy to prevent such complications. We aim to evaluate the prevalence of high-risk features among a cohort of patients with CD and examine the association between discordance of early therapy with baseline risk stratification and disease outcome.
Methods: All adult patients with CD were retrospectively identified and their medical records were reviewed. Clinical, endoscopic, laboratory and radiological data were collected. Patients were divided into “low” and “high” risk groups according to the presence or absence of penetrating disease, perianal involvement, foregut involvement, extensive disease seen on endoscopy or cross sectional imaging, young age at the time of diagnosis (<40), persistent cigarette smoking and frequent early requirements for corticosteroid therapy. Initial treatment selection and treatment approach (“step up” vs. “accelerated step-up” vs. “top-down”) within 6 months of diagnosis was recorded. Rates of CD-related bowel resections and hospitalization within 5 years of diagnosis were calculated. Logistic regression analysis was used to examine the association between “discordance” of early treatment selections and risk stratification categories with outcomes.
Results: Eighty-five CD patients were included. Mean age and duration of disease were 27.1 (+-11.7) and 6.4 (+- 4.8) years, respectively. Sixty five percent were females and 66% were native Saudi's. Smoking was reported in 12% of patients and perianal disease in 18%. “High-risk” features were identified in 51% of which only 14% were treated with “top-down” therapy and 16% “accelerated step-up” care. “Discordance” occurred in 34% of cases. Bowel resection was required for 15/85 (18%) patients and 32/85 (38%) required at least one hospitalization within 5 years of diagnosis. Logistic regression analysis identified a statistically significant association between “discordance” and need for bowel resections (Odds ratio (OR) = 6.50, 95% confidence interval (CI): 1.59–26.27, p=0.009), and hospitalizations (OR=3.01, 95% CI: 1.08–8.39, p=0.035) within 5 years of diagnosis.
Conclusions: “Discordance” between patient risk-profile and treatment selection early in the course of CD has a significant influence on disease outcome, specifically need for bowel resection and hospitalization. Early identification of “high-risk” features could help prevent long-term complications.