Abstract
Starting biologic treatment early in the course of inflammatory bowel disease (IBD) may be associated with higher efficacy, especially in Crohn's disease (CD). This was a systematic review and individual-patient data meta-analysis of all placebo-controlled trials of biologics approved for IBD at study inception (October 2015), using Vivli data-sharing platform. The primary outcome was the proportional biologic/placebo treatment effect on induction of remission in patients with short-duration (≤18 months) vs long-duration disease (>18 months) analyzed separately for CD and ulcerative colitis (UC). We used meta-regression to examine the impact of patients' characteristics on the primary outcome. We included 25 trials, testing infliximab, adalimumab, certolizumab, golimumab, natalizumab, or vedolizumab (6168 patients with CD and 3227 patients with UC). In CD, remission induction rates were higher in pooled placebo and patients in active arms with short-duration disease of ≤18 months (41.4% [244 of 589]) compared with disease duration of >18 months (29.8% [852 of 2857], meta-analytically estimated odds ratio, 1.33; 95% confidence interval, 1.09-1.64). The primary outcome, proportional biologic/placebo treatment effect on induction of remission, was not different in short-duration disease of ≤18 months (n= 589, odds ratio, 1.47; 95% confidence interval, 1.01-2.15) compared with longer disease duration (n= 2857, odds ratio, 1.43; 95% confidence interval, 1.19-1.72). In UC trials, both the proportional biologic/placebo remission-induction effect and the pooled biologic-placebo effect were stable, regardless of disease duration. Primary outcome results remained unchanged when tested using alternative temporal cutoffs and when modeled for individual patient's covariates, including prior anti-tumor necrosis factor exposure. There are higher rates of induction of remission with biologics and with placebo in early CD, resulting in a treatment to placebo effect ratio that is similar across disease durations. No such relationships between disease duration and outcomes was found in UC. PROSPERO registration: CRD42018041961.
Highlights
AND AIMS: Starting biologic treatment early in the course of inflammatory bowel disease (IBD) may be associated with higher efficacy, especially in Crohn’s disease (CD)
The predefined primary outcome of treatment effect, that is, the proportional biologic/placebo relative risk (RR) for remission at the end of induction, was not different in the 589 patients with short disease duration of 18 months (OR, 1.47; 95% confidence interval (CI), 1.01–2.15) compared with the 2857 patients with long duration of disease (OR, 1.43; 95% CI, 1.19–1.72) (Figure 2)
Similar to the induction results, the relative rate of maintenance of remission by biologics vs placebo was not different between patients with shortdisease duration (RR, 1.15; 95% CI, 0.91–1.44) compared with patients with >18 months of disease (RR, 1.15; 95% CI, 1.04–1.24)
Summary
AND AIMS: Starting biologic treatment early in the course of inflammatory bowel disease (IBD) may be associated with higher efficacy, especially in Crohn’s disease (CD). The primary outcome was the proportional biologic/placebo treatment effect on induction of remission in patients with short-duration (18 months) vs long-duration disease (>18 months) analyzed separately for CD and ulcerative colitis (UC). The primary outcome, proportional biologic/placebo treatment effect on induction of remission, was not different in short-duration disease of 18 months (n 1⁄4 589, odds ratio, 1.47; 95% confidence interval, 1.01–2.15) compared with longer disease duration (n 1⁄4 2857, odds ratio, 1.43; 95% confidence interval, 1.19–1.72). CONCLUSIONS: There are higher rates of induction of remission with biologics and with placebo in early CD, resulting in a treatment to placebo effect ratio that is similar across disease durations. No such relationships between disease duration and outcomes was found in UC. Long duration of disease is thought to be associated with reduced efficacy of biologic treatment in patients with Crohn’s disease
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