Prevalence, characteristics, management, and outcomes of difficult-to-treat inflammatory bowel disease

Background and Aims: Criteria for "difficult-to-treat"inflammatory bowel disease (DTT-IBD) have recently been proposed to standardize terminology. We aimed to evaluate the prevalence, characteristics, management, and outcomes of DTT-IBD. Methods: We conducted a retrospective study in 2 tertiary centers in Italy. Results: Among 1736 IBD patients treated with biologics/advanced small molecules, 430 (24.8%) met at least 1 DTT-IBD criterion, of which 331 (77%) failed at least 2 mechanisms of action. In ulcerative colitis (UC), left-sided and extended colitis were risk factors for DTT compared to proctitis (odds ratio [OR] 6.55; 95% confidence interval [CI], 1.93-40.98; p=0.011 and OR 10.12; 95% CI, 3.01-63.14; p=0.002, respectively). In Crohn's disease (CD), multiple localizations (L3+L4) (OR 3.04; 95% CI, 1.09-8.34; p=0.03), stricturing (OR 2.24; 95% CI, 1.52-3.34; p<0.001), and penetrating (OR 2.33; 95% CI, 1.55-3.53; p<0.001) behaviors, and perianal disease (OR 2.49; 95% CI, 1.75-3.53; p<0.001) were the main risk factors for DTT. Delay in advanced treatment initiation was positively associated with DTT-CD (OR 1.74; 95% CI, 1.27-2.41; p=0.001) but protective in UC (OR 0.65; 95% CI, 0.45-0.93; p=0.019). The rates of symptomatic, biochemical, and endoscopic remission were lower in DTT-IBD compared to non-DTT-IBD. The difference was most evident for endoscopic remission (25% vs 62%). Drug persistency in each following line of treatment progressively decreased in CD and UC. All advanced drugs used in DTT-IBD had similar persistence. Conclusions: DTT-IBD was prevalent in approximately one-quarter of patients with IBD in a tertiary care setting. Certain IBD phenotypes and the delay in initiating treatment in CD were risk factors for DTT. Drug persistency decreased progressively with every subsequent line of therapy.

Background and Aims: Criteria for "difficult-to-treat"inflammatory bowel disease (DTT-IBD) have recently been proposed to standardize terminology. We aimed to evaluate the prevalence, characteristics, management, and outcomes of DTT-IBD. Methods: We conducted a retrospective study in 2 tertiary centers in Italy. Results: Among 1736 IBD patients treated with biologics/advanced small molecules, 430 (24.8%) met at least 1 DTT-IBD criterion, of which 331 (77%) failed at least 2 mechanisms of action. In ulcerative colitis (UC), left-sided and extended colitis were risk factors for DTT compared to proctitis (odds ratio [OR] 6.55; 95% confidence interval [CI], 1.93-40.98; p=0.011 and OR 10.12; 95% CI, 3.01-63.14; p=0.002, respectively). In Crohn's disease (CD), multiple localizations (L3+L4) (OR 3.04; 95% CI, 1.09-8.34; p=0.03), stricturing (OR 2.24; 95% CI, 1.52-3.34; p&lt;0.001), and penetrating (OR 2.33; 95% CI, 1.55-3.53; p&lt;0.001) behaviors, and perianal disease (OR 2.49; 95% CI, 1.75-3.53; p&lt;0.001) were the main risk factors for DTT. Delay in advanced treatment initiation was positively associated with DTT-CD (OR 1.74; 95% CI, 1.27-2.41; p=0.001) but protective in UC (OR 0.65; 95% CI, 0.45-0.93; p=0.019). The rates of symptomatic, biochemical, and endoscopic remission were lower in DTT-IBD compared to non-DTT-IBD. The difference was most evident for endoscopic remission (25% vs 62%). Drug persistency in each following line of treatment progressively decreased in CD and UC. All advanced drugs used in DTT-IBD had similar persistence. Conclusions: DTT-IBD was prevalent in approximately one-quarter of patients with IBD in a tertiary care setting. Certain IBD phenotypes and the delay in initiating treatment in CD were risk factors for DTT. Drug persistency decreased progressively with every subsequent line of therapy.