Biologics and the timing of operative management of pediatric inflammatory bowel disease

Abstract

Purpose: Biologic disease-modulating antirheumatic drugs have altered the management of inflammatory bowel disease, reserving surgery for patients who fail pharmaceutical therapies. As a result of this, it may lead to the use of an increasing number of independent biologic medications before failure is declared. We hypothesize that biologic use beyond two independent medications without signs of remission will ultimately result in surgical management. Methods: We conducted retrospective chart review of patients with IBD treated at Children's Hospital Los Angeles between 2015 and 2018. We collected demographics and nutritional and inflammatory markers at diagnosis. Treatment regimens were recorded. Patients who never received biologics or received surgery prior to biologics were excluded. Cohorts were matched one-to-two. Results: We identified 43 operative and 86 non-operative patients. The duration of biologic usage varied significantly. On average, operative patients failed their first biologic within 10.8 months of use, while non-operative patients remained on it for 20.4 months. Of the patients who received more than two biologics 70% were from the operative cohort. Ultimately, the odds of requiring operative management doubled with for each additional biologic medication a patient received after the first (OR 2.16; 95 % CI (1.35–3.58)). Conclusion: Pediatric IBD patients who trial more than two biologics frequently proceed on to surgery. Therefore, failure of two biologics warrants surgical consideration. Additionally, patients who fail their first biologic in less than 12 months should be more closely followed and receive earlier surgical referral. Level of Evidence: Level III

Keywords

• Biologics
• Inflammatory bowel disease
• Pediatric
• Crohn's
• Colitis
• Autoimmune