Background: The recognition that chronic uncontrolled inflammation in Crohn's disease (CD) results in poor outcomes has led to the belief that early intervention with immunosuppressive (IS) and biologic therapy is associated with an increased probability of mucosal healing, early sustained remission without steroids and reduction in the need for surgery and hospitalisations. Given the risks of IS therapy, efforts are currently made to predict at diagnosis the subsequent behaviour of the disease, so that only patients with a predisposition for a disabling disease course should be considered for early intensive therapy.
The aim of our study was to identify at diagnosis factors predictive of a subsequent disabling course in CD.
Methods: All patients with a non-stricturing and non-penetrating CD newly diagnosed at our department during January 2009-December 2012 were included. Data regarding demography, phenotype, endoscopy and biochemistry at diagnosis was analyzed. The endpoint was disabling disease, previously defined as sustained disabling symptoms, need for hospitalisation for flare-up or complication (stenosis, abscess or fistulae) of the disease, need for repeated courses of steroids, need for IS therapy and need for intestinal and/or perianal surgery. Statistical analysis: X2, Student's t-test, Kaplan-Meier survival curves, Log-rank test, Cox regression. Significance: p<0.05.
Results: Fifty-nine patients were included, 50.8% (n=30) were men, with a mean age of 36 years. Disabling disease occurred in 76.3% (n=45), with a cumulative risk of 76% at 5-years of follow-up. Among the parameters analysed, factors significantly associated with disabling disease included younger ages (p=0.006), small-bowel location (p=0.003), higher C-reactive protein (CRP) (p=0.007), involvement of rectum (p=0.009) and severe endoscopic lesions (p=0.03). In multivariate analysis, none of the above parameters was independently associated with disabling disease. Conversely, factors significantly associated with time to disabling disease included younger ages (p=0.008), small-bowel location (p=0.004), colonic location (p=0.04), higher CRP (p=0.01), steroids requirement at diagnosis (p=0.03), perianal disease (p=0.04), rectal involvement (p=0.01) and severe endoscopic lesions (p=0.02). Of these, perianal disease (p=0.01) and CRP (p=0.03) were independent predictive factors of early disabling disease.
Conclusions: Age of onset, small-bowel location, CRP, rectal involvement and severe endoscopic lesions were associated with disabling disease. Perianal disease and CRP independently predict an early disabling course.