Intensified drug therapy leads to better stricture morphology in CD

The long-term results of the STRIDENT study demonstrated that an intensified treatment regimen results in less inflammation, a reduced treatment failure, and better Crohn’s disease (CD) stricture morphology. Participants with a clinical response at 12 months were less likely to undergo surgery at 24 months.

Is there a long-term benefit of an intensified regimen for strictures in CD and the need for surgery? To answer this question, the randomised-controlled STRIDENT study (NCT03220841) was performed. Previous results of the STRIDENT trial showed that CD symptomatic strictures respond to anti-TNF therapy: most participants clinically improved after a 12-month treatment with an intensified treat-to-target regimen of adalimumab +/- thiopurines [1]. Dr Julien Schulberg (St Vincent’s Hospital Melbourne, Australia) presented the 2-year follow-up data that assessed the response durability and risk of surgery [2].

In the study, participants were randomised to receive a high dose adalimumab induction, 160 mg weekly for 4 weeks, followed by 40 mg fortnightly plus thiopurine, with an adalimumab dose increase at 4 and/or 8 months if there was evidence of ongoing inflammation (n=52), or standard-dose adalimumab monotherapy (n=25). The primary study endpoint was the obstructive symptoms score (OSS) at 12 months.

This endpoint was achieved by 79% of the participants in the intensive arm compared with 64% in the standard arm (P=0.17). “The majority of patients had symptomatic improvement, and improvement was more likely in the intense treatment arm,” Dr Schulberg said. In addition, fewer participants in the intense-treatment arm had a treatment failure at 12 months.

Between 12 and 24 months, only 3 patients ceased adalimumab in the intensive arm but 13 decreased the dose. In the first 12 months, 9% of participants had surgery and a further 10% in the next 12 months. Notably, participants with a clinical response at 12 months were less likely to have surgery at 2 years (9% vs 42%; P=0.003). However, the total rates of surgery were not different between the standard and intensive therapy arms at 2 years (see Figure).

Figure: No difference in total rates of surgery over 24 months between intensified and standard treatment [1]



Dr Schulberg concluded that most CD strictures are responsive to drug treatment. Intense treat-to-target treatment results in reduced treatment failure, less inflammation, and better stricture morphology. Moreover, stricture bowl damage is often reversible with 20% of patients achieving objective complete stricture resolution.

 

1. Schulberg JD, et al. Lancet Gastroenterol Hepatol. 2022;7(4):318–331.
2. Schulberg J, et al. Crohn’s Disease Strictures Respond to Drug Treatment and Treat-to-Target Intense Combination Therapy is More Effective than Standard Anti-TNF Therapy. Two-year results of the STRIDENT Randomised Controlled Trial. DOP85, ECCO 2023, 1–4 March, Copenhagen, Denmark.

Posted on 4 May 202316 February 2024