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Top-down infliximab superior to step-up in children with CD

Presented by
Dr M. Jongsma, Erasmus MC, the Netherlands
ECCO 2020
Usually, a step-up treatment strategy is applied for infliximab in paediatric Crohn’s disease (CD) patients. In a first-ever direct comparison however, a top-down strategy was superior to step-up in achieving sustained clinical remission [1]. The authors therefore advise to start infliximab directly after diagnosis in moderate-to-severe paediatric CD.

Study presenter Myrthe Jongsma (Erasmus MC, the Netherlands) received an award for best investigator-initiated abstract at the ECCO-IBD 2020 meeting. Eligible patients in this study were aged 3–17
years and had new-onset, untreated disease with a weighted paediatric CD activity index (wPCDAI) >40. Top-down treatment consisted of 5 infliximab (CT-P13) infusions of 5 mg/kg (in week 0, 2, 6, 14, and 22) combined with azathioprine. Step-up treatment comprised exclusive enteral nutrition or oral prednisolone as induction, plus azathioprine as maintenance treatment. The primary endpoint was sustained clinical remission (wPCDAI <12.5) at week 52 without additional therapy or surgery. A total of 97 patients were randomised to top-down (n=49) or step-up (n=48).

After 52 weeks, significantly more patients in the top-down group were in clinical remission (44%) than in the step-up group (17%; P=0.004). Infliximab was (re)started after induction therapy in 39% of top-down versus 62% of step-up patients (P=0.019). After 10 weeks, top-down- compared with step-up-treated patients had higher clinical remission rates (61% vs 39%; P=0.033), higher endoscopic remission rates (59% vs 17%; P=0.001), and more frequent faecal calprotectin levels of <250 μg/g (53% vs 26%; P=0.027).

    1. Jongsma M, et al. ECCO-IBD 2020, OP38.


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