Tumor necrosis factor (TNF) inhibitor use early after a Crohn’s disease diagnosis was associated with reduced healthcare utilization in the ensuing years, but the same benefit was not observed with ulcerative colitis, health administrative data from Canada indicated.
Among over 700 patients with a Crohn’s disease diagnosis from 2001 to 2018 in Manitoba, the rates of outpatient visits, inflammatory bowel disease (IBD)-specific hospitalizations, and all-cause hospitalizations were all lower for those who initiated TNF inhibitors within 2 years rather than at 2 years or later, reported Laura Targownik, MD, MSHS, of the University of Toronto, and colleagues.
Using inverse probability treatment weighting, adjusted rates of outpatient visits were 14.8 per year in the group of Crohn’s disease patients that started TNF inhibitors early, as compared to 19.1 per year for those that started later, for an incidence rate difference (IRD) of -4.3 (95% CI -5.4 to -3.2), according to the findings in Clinical Gastroenterology and Hepatology.
For IBD-specific and all-cause hospitalizations within 5 years for the Crohn’s group, the adjusted rates per 100 person-years for the early and later treatment groups, respectively, were:
- IBD-specific: 4.0 vs 8.6 (IRD -4.5 per 100 person-years, 95% CI -7.0 to -2.1)
- All-cause: 23.1 vs 33.5 (IRD -10.4 per 100 person-years, 95% CI -17.0 to -3.7)
And the average total cost of care within 5 years was also lower with earlier anti-TNF use, at $23,469 versus $34,800 with later use (P<0.0001), the study found.
“The findings are intuitive, but it is still useful to see the magnitude of the impact of earlier anti-TNF initiation on subsequent healthcare utilization in CD [Crohn’s disease],” Targownik told MedPage Today. “We need to better understand which patients with CD benefit most from earlier exposure to biologic therapy, and to explore why similar benefits were not seen in UC [ulcerative colitis].”
Timely intervention with biologic therapy reduces inflammation, which in turn can ease the burden of fibrotic disease and lower the risk of complications or need for surgical interventions, Targownik’s group noted, but the optimal timing for initial treatment with these agents remains unclear.
In the Crohn’s disease group, the need for resective surgery was no different between early and later anti-TNF initiators, though a post-hoc analysis that excluded the first year of anti-TNF treatment suggested a possible benefit for the early group (IRD -3.6 per 100 person-years 95 % CI -5.3 to -1.9).
“The important study adds to the evidence suggesting that biologic therapy, particularly anti-TNF therapy, can alter the natural course of Crohn’s disease,” said Gil Melmed, MD, of Cedars-Sinai Medical Center in Los Angeles, who was not involved in this study. “This ‘window of opportunity’ earlier in the course of the disease is when these medications have the greatest impact, before accumulated bowel damage may render such therapy less effective.”
For their study, Targownik and colleagues examined health administrative claims data on 1,060 patients who were newly diagnosed with IBD from 2001 to 2018, as defined by ICD-9 codes, and used a TNF inhibitor at some point in their disease course: 742 with Crohn’s disease and 318 with ulcerative colitis. Patients had to have a minimum of 1 year of follow-up for inclusion.
Inverse probability treatment weighting adjusted for baseline differences such as demographics, year of initial anti-TNF use, history of resection, and others among groups.
The average duration from diagnosis to anti-TNF initiation was 4.4 years. Over half of the Crohn’s disease patients were women (52-59%), the average age was 30 to 41 years at the time of anti-TNF initiation, and most were on infliximab (Remicade; 67-83%). Over half of the ulcerative colitis patients were men (51-62%), with a mean age of 32 to 43 years at anti-TNF initiation, with nearly all on infliximab (91-95%).
The authors acknowledged several limitations to the data, including that patients who initiate early anti-TNF therapy may present with more aggressive disease and inherently require a greater use of healthcare resources than those who initiate therapy later. The ulcerative colitis group may have been underpowered to detect any potential benefit.
Zaina Hamza is a staff writer for MedPage Today, covering Gastroenterology and Infectious disease. She is based in Chicago.
Targownik disclosed relationships with AbbVie, Amgen, Janssen, Merck, Pfizer, Roche, Sandoz, and Takeda.
Coauthors reported relationships with AbbVie, Amgen, Avir, Bristol Myers Squibb, Guardant Health, Hoffman La-Roche Limited and Peabody & Arnold LLP, Janssen, McKesson, Medtronic, Merck, Mylan Pharmaceuticals, Pendopharm, Pfizer, Roche, Sandoz, Shire, and Takeda.