Immunomodulators are associated with a lower risk of first surgery among patients with non-penetrating non-stricturing Crohn's disease.

OBJECTIVES: Early immunomodulator therapy may alter the natural history of Crohn's disease in certain patients. We determined whether immunomodulator use was associated with a lower risk of first surgery among patients with non-stricturing non-penetrating Crohn's disease. METHODS: A total of 159 consecutive patients with non-penetrating non-stricturing Crohn's disease from 1994 to 2005 were retrospectively identified and followed from diagnosis to either first surgery (surgery group) or last clinic follow-up (medication group) in a historical cohort analysis. Immunomodulator use, duration, disease location, age at diagnosis, smoking, family history, and decade of diagnosis were compared. Cox proportional hazards models were adjusted for propensity score to determine whether immunomodulator use lasting >6 months decreased the risk of first surgery and whether duration of therapy affected risk. RESULTS: The median duration of follow-up was similar (6.0 vs. 5.5 years), age at diagnosis 10 years earlier, and isolated colonic disease three times less common (18 vs. 49%) in the surgery group as compared with the medication group. Immunomodulator use increased with time but overall was less common in the surgical group (24 vs. 48%). In the multivariate Cox proportional hazards model immunomodulator use was associated with a lower risk of surgery (hazard ratio, 0.41; 95% confidence interval 0.21-0.81) after adjustment for propensity score. Similarly, risk of surgery declined with duration of use. CONCLUSIONS: Immunomodulator use is associated with a decreased risk of first surgery among patients with non-stricturing non-penetrating CD. Early immunomodulator therapy may be beneficial in preventing first surgery in this population that has yet to develop penetrating or fistulizing complications.

Oral mesalamine and clinical remission are associated with a decrease in the extent of long-standing ulcerative colitis.

OBJECTIVE: To compare colonoscopy alone with surveillance biopsy for the determination of anatomic extent in long-standing ulcerative colitis (UC). To assess the influences of mesalamine use and clinical disease activity on the change of histologic extent with time. MATERIALS AND METHODS: Disease extent (proctosigmoiditis, left-sided colitis, or pancolitis) measured by colonoscopy and surveillance biopsy was compared among 212 consecutive patients with long-standing UC. Among the 102 patients who had 2 consecutive colonoscopies with surveillance biopsies, the following influences on change in histologic extent were determined: disease activity, mesalamine use, age at disease onset, folic acid, corticosteroid and azathioprine/6-mercaptopurine use, and time between colonoscopies. RESULTS: Agreement between gross and microscopic findings was poor (kappa = 0.39). Colonoscopy underestimated and overestimated extent in 25.9% and 8.5%, respectively. Microscopic distribution between consecutive colonoscopies remained the same in 60.8%. Where distribution changed, an increase was twice as common as a decrease in extent. There was no difference in age at onset, time between colonoscopies, or disease duration among those with an increase, decrease, or no change in extent. Clinical remission and oral mesalamine were independently associated with 10.7 and 5.8 times the odds of a decrease in disease extent, respectively. Folic acid, topical mesalamine, corticosteroids, and immunomodulators did not influence change in extent. CONCLUSIONS: UC extent is best determined by surveillance biopsy. Among patients with long-standing UC, histologic extent fluctuates with time. Disease remission and oral mesalamine were independently associated with decreases in disease extent.