Early vs Late Use of Anti-TNFa Therapy in Adult Patients With Crohn Disease: A Systematic Review and Meta-Analysis

Hamdeh S1, Aziz M2, Altayar O3, Olyaee M1, Murad MH4, Hanauer SB5. Inflamm Bowel Dis. 2020 Feb 17. pii: izaa031. doi: 10.1093/ibd/izaa031. [Epub ahead of print]


Author information

University of Kansas Medical Center, Internal Medicine Department, Division of Gastroenterology and Hepatology, Kansas City, Kansas, USA.

University of Toledo Medical Center, Department of Internal Medicine, Toledo, Ohio, USA.

Washington University School of Medicine, Internal Medicine Department, Division of Gastroenterology and Hepatology, St. Louis, Missouri, USA.

Mayo Clinic College of Medicine, Evidence-Based Practice Center, Rochester, Minnesota, USA.

Northwestern University Feinberg School of Medicine, Internal Medicine Department, Division of Gastroenterology and Hepatology, Chicago, Illinois, USA.


OBJECTIVES: While anti-tumor necrosis factor alpha (anti-TNFa) therapies for Crohn disease (CD) were initially introduced in 1998 for biologic therapies are often introduced after a minimum of 6 years after diagnosis. The benefit of anti-TNFa early in the course of CD is still controversial, with some studies showing better outcomes but others not. To determine whether earlier introduction of anti-TNFa therapy improves efficacy in clinical trials or clinical series, we aimed to perform a meta-analysis comparing early vs late anti-TNFa use in the management of CD.

METHODS: A comprehensive search of MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and Scopus was conducted from each database's inception to November 3, 2019. We included comparative studies of early vs late use of anti-TNFa therapy in adult patients with CD.

RESULTS: Eleven studies were included in the analysis, with a total of 2501 patients. Meta-analysis demonstrated that the early use of anti-TNFa was associated with a statistically significant decrease in the need for surgery (relative risk [RR] = 0.43; 95% confidence interval [CI], 0.26-0.69; I2 = 68%) and disease progression (RR = 0.51; 95% CI, 0.35-0.75; I2 = 61%). Early use also showed an increase in early remission (RR = 1.94; 95% CI, 1.54-2.46; I2 = 0%) and clinical response. There was no statistically significant difference in achieving late remission (RR = 1.39; 95% CI, 0.94-2.05; I2 = 65%) or mucosal healing (RR = 1.10; 95% CI, 0.63-1.91; I2 = 0%).

CONCLUSION: This systematic review suggests that using anti-TNFa earlier in the treatment of CD (within 3 years) may improve clinical outcomes compared to late administration in terms of achieving early clinical remission, clinical response, disease progression, and the need for surgery.

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