Selecting high-risk patients with paediatric Crohn’s disease for top-down anti-TNF as per the 2021 ECCO-ESPGHAN guidelines: A five-year nationwide retrospective analysis from Scotland (2016-2020)

TY - JOUR

T1 - Selecting high-risk patients with paediatric Crohn’s disease for top-down anti-TNF as per the 2021 ECCO-ESPGHAN guidelines

T2 - A five-year nationwide retrospective analysis from Scotland (2016-2020)

AU - Scott, Gregor

AU - Wands, David I. F.

AU - Wilson, David C.

AU - Hansen, Richard

AU - Chalmers, Iain

N1 - Copyright: © The Author(s) 2024. Published by Oxford University Press on behalf of Crohn’s & Colitis Foundation. All rights reserved. For commercial re-use, please contact [email protected] for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact [email protected].

PY - 2025/8/1

Y1 - 2025/8/1

N2 - Background: The 2021 ECCO-ESPGHAN guideline on the medical management of paediatric 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 paediatric patients (<17 years) diagnosed with Crohn’s disease in Scotland between 01/01/16 and 31/12/20 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 of 18 months follow-up post-diagnosis. Results: Four hundred and eighteen children (258/418 [62%] male; median (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<0.001) 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=0.01). 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.

AB - Background: The 2021 ECCO-ESPGHAN guideline on the medical management of paediatric 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 paediatric patients (<17 years) diagnosed with Crohn’s disease in Scotland between 01/01/16 and 31/12/20 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 of 18 months follow-up post-diagnosis. Results: Four hundred and eighteen children (258/418 [62%] male; median (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<0.001) 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=0.01). 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.

KW - Paediatric

KW - Crohn’s disease

KW - Anti-TNF

U2 - 10.1093/ibd/izae298

DO - 10.1093/ibd/izae298

M3 - Article

C2 - 39671376

SN - 1078-0998

VL - 31

SP - 2059

EP - 2065

JO - Inflammatory Bowel Diseases

JF - Inflammatory Bowel Diseases

IS - 8

ER -