Systematic review and network meta-analysis Medical therapies to prevent recurrence of post-operative Crohn's disease.

Background and Aims: Surgery is an important treatment for Crohn’s disease (CD) but recurrence occurs in up to 80% of individuals post-operatively. The efficacy of several drugs to prevent post-operative recurrence has been studied in previous meta-analyses, but a number of randomised controlled trials (RCTs) have recently been published. We therefore performed an updated systematic review and network meta-analysis to investigate this issue.

Methods: We performed a comprehensive literature search through to July 2018 to identify RCTs investigating the endoscopic and clinical recurrence of CD at 12 months post-operatively. We performed a random-effects network meta-analysis to produce a pooled relative risk (RR) with 95% confidence intervals (CIs). We ranked the treatments according to their P-score.

Results: We included ten RCTs, containing 751 patients, in our primary analysis of endoscopic recurrence of CD at 12 months. Anti-tumour necrosis factor (TNF)-α therapies were significantly better than placebo, either alone (P-score 0.98, RR 0.13; 95% CI 0.04 to 0.39) or in combination with 5-aminosalicylates (5-ASAs) (P-score 0.81, RR 0.30; 95% CI 0.12 to 0.75), or 5-nitroimidazoles (P-score 0.75, RR 0.40; 95% CI 0.23 to 0.69). Combination therapy with a thiopurine and 5-nitroimidazole was also more effective than placebo (P-score 0.59, RR 0.56; 95% CI 0.40 to 0.80), as was thiopurine monotherapy (P-score 0.31, RR 0.84; 95% CI 0.74 to 0.94). However, neither 5-nitroimidazoles nor 5-ASAs alone were superior to placebo.

Conclusions: In network meta-analysis anti-TNF-α therapies alone, or in combination, appear to be the best medications for preventing endoscopic post-operative recurrence of CD.