Background: The use of biologic agents, particularly anti-tumour necrosis factor (TNF) agents, is well established in Crohn's disease (CD). Historically, biologics were reserved for patients at surgical “risk”. However, therapeutic goals have continued to evolve since their introduction from clinical to endoscopic remission and, subsequently, histological remission. The aim of this study was to assess changes in medical and surgical therapies for Crohn's disease over the past 25 years with special reference to biologic use and smoking.
Methods: Data were extracted from a prospectively maintained university hospital IBD database. We divided our population into 3 groups according to diagnosis date, 1) “Pre-biologic” cohort (1990–2002) (n=550), 2) “Early biologic” cohort (2003–2008) (n=308) and, 3) “Established biologic” cohort (2009–2015) (n=250).
Results: 1,107 patients were included in the study. 554 patients underwent their first major surgery during the follow-up period, 332 (60.4%) in cohort 1 (1990–2002), 174 (56.5%) in cohort 2 (2003–2008), and 48 (19.2%) in cohort 3 (2009–2015). The risk of first major surgery decreased over calendar time from cohort 1 to cohort 3 (p<0.001, see Figure 1). The 1- and 5-year cumulative major surgical risk was 24.8% and 44.8% in cohort 1, 21.5% and 39.9% in cohort 2, and 14.3% and 22.1% in cohort 3. The cumulative probability of biologic use increased from cohort 1 to 3, with a 1 and 5-year cumulative risk of biologic use of 1.8% and 6.3% in cohort 1, 4.9% and 10.7% in cohort 2 to and 21.5% and 49.8% in cohort 3 (p<0.001). The 5-year cumulative risk of either first major surgery or biologic use in cohort 1, 2 and 3 was 48.3% and 46.9% and 61.3% (p=0.003). During the study period, smoking at diagnosis decreased from 38% in cohort 1 to 22% in cohort 3 (p<0.001).
Conclusions: The large decline in major surgery in recently diagnosed Crohn's disease patients is mirrored by a substantial increase in biologic use and a decrease in smoking over the same period. Continuous monitoring of therapeutic and social trends in clinical practice indicates substantial shifts in medical and surgical therapies and provides valuable data for service providers when planning future health care needs.