Postoperative recurrence of Crohn's disease is common.
Dr Roberto Candia and colleagues assessed whether the postoperative management should be based on biological therapy alone or combined with thiopurines and whether the therapy should be started immediately after surgery or guided by either endoscopic or clinical recurrence.
A Markov model was developed to estimate expected health outcomes in quality-adjusted life years (QALYs) and costs in Canadian dollars (CAD$) accrued by hypothetical patients with high recurrence risk after ileocolic resection.
The team evaluated 8 strategies of postoperative management.
|The second strategy has the highest probability of being the optimal alternative |
|Inflammatory Bowel Disease|
A lifetime time horizon, an annual discount rate of 5%, a societal perspective, and a cost-effectiveness threshold of 50,000 CAD$/QALY were assumed.
Deterministic and probabilistic sensitivity analyses were conducted.
The model was validated against randomized trials and historical cohorts.
The researchers reported that 3 strategies dominated the others, including endoscopy-guided full step-up therapy, thiopurines immediately post-surgery plus endoscopy-guided biological step-up therapy, and combination therapy immediately post-surgery.
The second strategy was the most cost-effective, assuming a cost-effectiveness threshold of 50,000 CAD$/QALY.
The research team showed that the second strategy has the highest probability of being the optimal alternative in all comparisons at cost-effectiveness thresholds from 30,000 to 100,000 CAD$/QALY.
The strategies guided only by clinical recurrence and those using biologics alone were dominated.
Dr Candia's team concludes, "According to this decision analysis, thiopurines immediately after surgery and addition of biologics guided by endoscopic recurrence is the optimal strategy of postoperative management in patients with Crohn's disease with high risk of recurrence."