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Selecting High-Risk Patients With Pediatric Crohn's Disease for Top-Down Anti-TNF as per the 2021 ECCO-ESPGHAN
Gregor Scott1, David I F Wands1,2, David C Wilson2,3
1Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK.
Insights
The 2021 ECCO-ESPGHAN guideline helps identify pediatric Crohn's disease patients needing early anti-TNF treatment. However, it risks over- or under-treatment, emphasizing flexible monitoring and adaptive strategies.
Area of Science:
- Pediatric Gastroenterology
- Inflammatory Bowel Disease Management
- Clinical Guideline Evaluation
Background:
- The 2021 ECCO-ESPGHAN guideline recommends early risk stratification for pediatric Crohn's disease.
- It promotes a top-down approach with anti-tumor necrosis factor (anti-TNF) therapy for high-risk patients.
Purpose of the Study:
- To objectively assess the risk-benefit profile of the current pediatric Crohn's disease management guideline.
- To evaluate the guideline's risk stratification accuracy and top-down anti-TNF guidance in a real-world setting.
Main Methods:
- A nationwide cohort study in Scotland included pediatric patients (<17 years) diagnosed with Crohn's disease from 2016-2020.
- The current management algorithm was retrospectively applied to assess risk stratification accuracy.
- Phenotypic and treatment data were collected with up to 18 months of follow-up.
Main Results:
- Of 418 children, 54% had a high-risk phenotype. 24% of high-risk patients did not require anti-TNF within 18 months.
- Conversely, 40% of low-risk patients received anti-TNF therapy within 18 months.
- High-risk patients were more likely to require anti-TNF (76% vs 40%) and started it sooner.
Conclusions:
- The guideline effectively identifies patients likely to need early treatment escalation.
- However, the approach risks significant over- and under-treatment.
- Frequent monitoring and flexible, adaptive treatment strategies are crucial for optimal pediatric Crohn's disease management.
Background:
The 2021 ECCO-ESPGHAN guideline on the medical management of pediatric Crohn's disease promotes early risk stratification and top-down anti-TNF for patients deemed high risk of severe disease course.
Aims:
We aimed to objectively assess the risk-benefit profile of the guideline's risk stratification policy and guidance on top-down anti-TNF in a nationwide population-based cohort study.
Methods:
Using a prospectively identified nationwide cohort of all new pediatric patients (<17 years) diagnosed with Crohn's disease in Scotland between January 1, 2016 and December 31, 2020 and retrospectively applying the current management algorithm, we explored the guideline's ability to accurately risk stratify patients. Phenotypic and treatment data were retrospectively collected from electronic medical records with a maximum follow-up of 18 months post-diagnosis.
Results:
Four hundred and eighteen children (258/418 [62%] male; median [interquartile range {IQR}] age at diagnosis: 13.2 [11.2-14.8] years) were included. High-risk phenotype was present in 224/418 (54%) with 53/224 (24%) of high-risk patients not requiring anti-TNF therapy within 18 months of diagnosis. Conversely, 78/194 (40%) of the low-risk group received anti-TNF within 18 months. High-risk patients were more likely to require anti-TNF (171/224 [76%] vs 78/194 [40%], P < .001) and had shorter median (IQR) time to anti-TNF start (5.0 [1.0-8.0] months vs 6.5 [3.3-13.0] months, P = .01).
Conclusions:
Our data support the guideline's ability to identify patients more likely to require early treatment escalation. However, this approach would have led to potential over- and under-treatment in a substantial proportion of patients. This underscores the importance of frequent and comprehensive monitoring, along with flexible treatment strategies that adapt to changes in disease status.
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