P756 Efficacy and safety of medical therapies for maintenance of surgically induced remission in Crohn’s disease: A systematic review and network meta-analysis

Abstract

Background
Approximately half of patients with Crohn’s disease (CD) undergo surgical resection in first decade after diagnosis. Majority experience disease recurrence following surgery requiring further intervention. There is limited evidence on efficacy of medical therapies in this setting. We performed a network meta-analysis to evaluate comparative efficacies of medical therapies for the prevention of clinical and endoscopic relapse after surgical resection.

Methods
We searched MEDLINE, Embase, and Cochrane Central Register of Controlled Trials between inception and October 2023 for randomised controlled trials (RCTs). Outcomes assessed were clinical relapse, endoscopic relapse, and safety outcomes including adverse events (AE), withdrawal due to AE, and serious AE. We performed random-effects network meta- analysis using a frequentist approach, and estimated relative risk (RRs), 95% CI values and used GRADE to ascertain certainty of evidence.

Results
A total of 37 RCTs comprising 4411 patients were included. On network meta-analysis of clinical relapse outcome, there was moderate certainty of evidence favouring adalimumab (RR 0.14, 95% CI [0.03-0.7]) over placebo with number needed to treat (NNT) of 3. There was low certainty of evidence supporting 5-amainosalycilates (RR 0.81, 95% CI [0.71-0.92]; NNT of 13) and purine analogues (RR 0.82, 95% CI [0.72-0.93]; NNT of 14) but the effect size was trivial (Figure 1). Whereas for endoscopic relapse outcome, vedolizumab (RR 0.23, 95% CI [0.07-0.8]) and adalimumab (RR 0.32, 95% CI [0.17-0.62], low certainty) and infliximab (RR 0.63, 95% CI [0.48-0.82], low certainty) were the only agents superior to placebo but not purine analogues (RR 0.87, 95% CI [0.7-1.08], very low certainty), 5-ASA (RR 1.04, 95% CI [0.85-1.26], very low certainty), antibiotics (RR 1.13, 95% CI [0.83-1.53], very low certainty), probiotics (RR 1.15, 95% CI [0.94-1.39], very low certainty), vitamin-D (RR 0.9, 95% CI [0.62-1.31], very low certainty) and curcumin (RR 1.17, 95% CI [0.73-1.87], low certainty). On analysis of total adverse events outcomes, all therapies were safe.

Conclusion
On network meta-analysis, adalimumab had a large magnitude of effect size for preventing clinical and endoscopic relapse (low certainty), vedolizumab a large magnitude for preventing endoscopic relapse (low certainty) and 5-ASA a small magnitude result for preventing clinical relapse (low certainty). Overall certainty of evidence is very low to low suggesting need for further research in this field.