Clinician Article
Comparative efficacy of pharmacologic interventions in preventing relapse of Crohn's disease after surgery: a systematic review and network meta-analysis.
PMID: 25263803
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Internal MedicineRelevance - 6/7
Newsworthiness - 6/7 -
GastroenterologyRelevance - 6/7
Newsworthiness - 5/7 -
Surgery - GeneralRelevance - 6/7
Newsworthiness - 5/7 -
Family Medicine (FM)/General Practice (GP)Relevance - 5/7
Newsworthiness - 4/7 -
General Internal Medicine-Primary Care(US)Relevance - 5/7
Newsworthiness - 4/7
Abstract
BACKGROUND & AIMS: There are several drugs that might decrease the risk of relapse of Crohn's disease (CD) after surgery, but it is unclear whether one is superior to others. We estimated the comparative efficacy of different pharmacologic interventions for postoperative prophylaxis of CD, through a network meta-analysis of randomized controlled trials.
METHODS: We conducted a systematic search of the literature through March 2014. We identified randomized controlled trials that compared the abilities of mesalamine, antibiotics, budesonide, immunomodulators, anti-tumor necrosis factor a (anti-TNF) (started within 3 months of surgery), and/or placebo or no intervention to prevent clinical and/or endoscopic relapse of CD in adults after surgical resection. We used Bayesian network meta-analysis to combine direct and indirect evidence and estimate the relative effects of treatment.
RESULTS: We identified 21 trials comprising 2006 participants comparing 7 treatment strategies. In a network meta-analysis, compared with placebo, mesalamine (relative risk [RR], 0.60; 95% credible interval [CrI], 0.37-0.88), antibiotics (RR, 0.26; 95% CrI, 0.08-0.61), immunomodulator monotherapy (RR, 0.36; 95% CrI, 0.17-0.63), immunomodulator with antibiotics (RR, 0.11; 95% CrI, 0.02-0.51), and anti-TNF monotherapy (RR, 0.04; 95% CrI, 0.00-0.14), but not budesonide (RR, 0.93; 95% CrI, 0.40-1.84), reduced the risk of clinical relapse. Likewise, compared with placebo, antibiotics (RR, 0.41; 95% CrI, 0.15-0.92), immunomodulator monotherapy (RR, 0.33; 95% CrI, 0.13-0.68), immunomodulator with antibiotics (RR, 0.16; 95% CrI, 0.04-0.48), and anti-TNF monotherapy (RR, 0.01; 95% CrI, 0.00-0.05), but neither mesalamine (RR, 0.67; 95% CrI, 0.39-1.08) nor budesonide (RR, 0.86; 95% CrI, 0.61-1.22), reduced the risk of endoscopic relapse. Anti-TNF monotherapy was the most effective pharmacologic intervention for postoperative prophylaxis, with large effect sizes relative to all other strategies (clinical relapse: RR, 0.02-0.20; endoscopic relapse: RR, 0.005-0.04).
CONCLUSIONS: Based on Bayesian network meta-analysis combining direct and indirect treatment comparisons, anti-TNF monotherapy appears to be the most effective strategy for postoperative prophylaxis for CD.
Clinical Comments
Family Medicine (FM)/General Practice (GP)
A fine review with challenging methods, but still able to convey a clear clinical message.
Gastroenterology
This is an important study, but for those tempted just to read the abstract, the final couple of sentences of the discussion are important: "Large RCTs are warranted to establish the comparative efficacy of different strategies for postoperative CD. Cost-utility analyses are also warranted to individualize a strategy for postoperative prophylaxis more definitively, depending on the risk of recurrence after surgical resection of CD."
Surgery - General
This is definitely not bedtime reading. Exercises in evidence based medicine are gathering complexity in a number of fields, but perhaps mostly in the field of multiple intervention reviews in which one endeavors to determine across a number of publications which of many interventions might be best. This publication does that in a meticulous way and will leave your head spinning. However, their conclusions do seem well founded and for anyone responsible for the care of IBD very relevant.
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