Optimal use of biologics with endoscopic balloon dilatation for repeated intestinal strictures in Crohn's disease

Background and Aim Intestinal strictures in Crohn's disease (CD) have a high rate of repeated surgery. As alternatives to surgery, endoscopic balloon dilatation (EBD), immunomodulators (IMs), and antitumor necrosis factor alpha (anti-TNF alpha) have been proposed. We aimed to assess the effectiveness of the combined therapy with anti-TNF alpha and EBD in preventing intestinal stricture recurrence and surgery in patients with CD. Methods This retrospective cohort study included patients from the nationwide administrative database in Japan who were hospitalized and underwent at least one EBD between 1 April 2010 and 31 March 2017. The effectiveness of anti-TNF alpha was evaluated by performing survival analysis for the primary outcome. We selected the inverse probability of treatment weighting method for adjustment of covariates. As an exploratory analysis, we evaluated the association of anti-TNF alpha initiation timing with intestinal stricture recurrence. Results The anti-TNF alpha exposed group had a significantly lower risk of intestinal stricture recurrence than that of the anti-TNF alpha nonexposed group (hazard ratio = 0.38, 95% confidence interval 0.31-0.48, P < 0.001). Surgery-free rate was shown to have the same tendency. Anti-TNF alpha therapy initiation before or after EBD resulted in a lower risk of intestinal stricture recurrence than that of simultaneous treatment. Conclusion The combined therapy with anti-TNF alpha and EBD could have preventive effects for intestinal stricture recurrence and surgery in hospitalized patients with CD. In particular, anti-TNF alpha initiation may be recommended before or after EBD, not immediately after EBD. With respect to EBD, it is important to clarify the effectiveness of combination therapy with several new medication treatments, such as biologics.