P-206 YI Disease Progression in Pediatric Patients with Crohnʼs Disease on Biologic Therapy

Abstract

The use of infliximab and adalimumab has become standard treatment options for pediatric patients with Crohn's disease. Initiating these therapies when they would be most effective would benefit those patients most at risk of rapid disease progression. Hence, the ongoing debate exists regarding step up versus top down treatment strategies. We present 3 patients with severe Crohn's disease with significant disease progression rapidly escalating to biologic therapy. Case Series: 19-year-old M diagnosed with Crohn's disease at age 7. Since diagnosis he has had recurrent perianal abscesses requiring seton placement. Initially he was treated with 5ASA's, and immunomodulators. At age 11 he was started on infliximab. By age 12, due to poor response, he was started on adalimumab with dose escalated to weekly therapy by age 17. At age 19 Crohn's disease activity index remains moderate. 16-year-old F diagnosed with Crohn's disease at age 9. Disease course was complicated by failure to thrive with gastrostomy tube placement, worsening perirectal disease, and multiple hospitalizations. She was initially managed with 5 ASAs then thiopurines. Due to ongoing disease activity, therapy was escalated to Infliximab at age 11. She subsequently developed HACA antibodies. Following a short course of adalimumab, Cimzia was started in conjunction with methotrexate. Colonoscopy at age 16 showed a new stricture at the hepatic flexure. Therapy was escalated to vedolizumab. 8 yo male diagnosed with Crohn's disease at age 4. Disease course was complicated by perianal fistula, poor growth, and frequent flares despite treatment with sulfasalazine then thiopurines. Due to poor control, he was switched to infliximab. He subsequently developed HACA antibodies and was started on adalimumab at age 6. Colonoscopy at age 8 showed significant disease. Methotrexate was added to treatment regimen. Crohn's disease is a chronic, progressing inflammatory disorder. Crohn's patients with perianal involvement have a higher risk of disease complication including abscesses, fistulae, and stricture formation, as these cases demonstrate. Conventional guidelines for management of Crohn's disease utilize a step-up approach with corticosteroids +/− aminosalicylates as first line, followed by thiopurines then biologics. All 3 patients, despite moderate to severe Crohn's disease at diagnosis, were treated conservatively. Prior to therapy escalation all 3 continued to have active moderate to severe disease, raising the question of early use of biologic therapy. A recent retrospective study by Lee et al showed that treatment with infliximab leads to a longer remission period thereby indicating that biologics should be used earlier in patients with moderate to severe disease. Parents and physicians are often reluctant to step up therapy due to concerns of serious adverse effects. N/A Patients diagnosed with severe IBD tend to progress to biological therapy after having been sub-optimally controlled for several years. Parental and physician reluctance to step up therapy due to concerns of potential serious adverse effects may play a role in disease progression leading to patients often functioning at a suboptimal quality of life when compared to their peers.