Issue 22

Clinical Question

Is there a simple durability tool that will help patients with Crohn’s disease understand the benefits of remaining on medication?

Editor’s Bottom Line

The NND/NNT tool can help physicians explain the benefits of remaining on therapy. Anti-TNF therapy outperforms azathioprine/6-mercaptopurine and methotrexate using this tool.

Reference

Shah ED, Siegel CA, Chong K, Melmed GY. Patients with Crohn’s Disease Are More Likely to Remain on Biologics than Immunomodulators: A Meta-Analysis of Treatment Durability. Dig Dis Sci. 2015;60:2408–18.
https://www.ncbi.nlm.nih.gov/pubmed/25772778

Synopsis

In this meta-analysis, double-blind, randomized, placebo-controlled trials or recent phase III clinical trials (n=3) for induction and/or maintenance of CD patients with moderate-to-severe disease (CDAI: 220-450) were included.

The studies assessed the efficacy of immunomodulators (azathioprine/6-mercaptopurine, n=6; methotrexate, n=4) and biologics (adalimumab, certolizumab, infliximab, natalizumab, and vedolizumab; n=21). Therapy durability was defined as patients who discontinued the study due to adverse event or disease exacerbation (number needed to discontinue: NND). Therapy efficacy was defined by number needed to treat (NNT). The NND/NNT ratio was the primary endpoint with higher values indicating more durable and effective therapies.

Azathioprine/6-mercaptopurine for maintenance were associated with more discontinuations than remission (NND/NNT = 0.9). There were no induction trials for azathioprine/6-mercaptopurine. Azathioprine/6-mercaptopurine had a combined induction and maintenance NND/NNT = 7.4.

Methotrexate for induction had more remission than discontinuations (NND/NNT = 1.4). There was only a single maintenance trial for methotrexate. Methotrexate had a combined induction and maintenance NND/NNT = 3.7.

Anti-TNF agents had an induction and maintenance NND/NNT = 37.9.

Details

Study Design: Meta-analysis
Funding: N/A
Allocation: N/A
Setting: Various
Level of Evidence: 1a (Oxford Levels of Evidence)

The summary and conclusion in this issue of E-mentoring in IBD pertains to the manuscript(s) being reviewed, and should be considered in the context of what is already known surrounding the topic and incorporated into practice as deemed appropriate by the individual learner.