Reena Khanna1, Brian Bressler2, Barrett G Levesque3, Guangyong Zou4, Larry W Stitt5, Gordon R Greenberg6, Remo Panaccione7, Alain Bitton8, Pierre Paré9, Séverine Vermeire10, Geert D'Haens11, Donald MacIntosh12, William J Sandborn3, Allan Donner4, Margaret K Vandervoort5, Joan C Morris5, Brian G Feagan13. 1. Robarts Clinical Trials Inc, Robarts Research Institute, London, ON, Canada; Department of Medicine, University of Western Ontario, London, ON, Canada. 2. Department of Gastroenterology, St Paul's Hospital, Vancouver, BC, Canada. 3. Robarts Clinical Trials Inc, Robarts Research Institute, London, ON, Canada; Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA. 4. Robarts Clinical Trials Inc, Robarts Research Institute, London, ON, Canada; Department of Epidemiology and Biostatistics, University of Western Ontario, London, ON, Canada. 5. Robarts Clinical Trials Inc, Robarts Research Institute, London, ON, Canada. 6. Division of Gastroenterology, Mount Sinai Hospital, Toronto, ON, Canada. 7. Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada. 8. Division of Gastroenterology, McGill University Health Centre, McGill University, Montreal, QC, Canada. 9. Laval University, CHAUQ, Hôpital du St-Sacrement, Quebec City, QC, Canada. 10. Department of Clinical and Experimental Medicine, Translational Research Center for Gastrointestinal Disorders, Leuven, Belgium. 11. Robarts Clinical Trials Inc, Robarts Research Institute, London, ON, Canada; Department of Gastroenterology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands. 12. Division of Gastroenterology, Dalhousie University, Halifax, NS, Canada. 13. Robarts Clinical Trials Inc, Robarts Research Institute, London, ON, Canada; Department of Medicine, University of Western Ontario, London, ON, Canada; Department of Epidemiology and Biostatistics, University of Western Ontario, London, ON, Canada. Electronic address: brian.feagan@robartsinc.com.
Abstract
BACKGROUND:Conventional management of Crohn's disease features incremental use of therapies. However, early combined immunosuppression (ECI), with a TNF antagonist and antimetabolite might be a more effective strategy. We compared the efficacy of ECI with that of conventional management for treatment of Crohn's disease. METHODS: In this open-label cluster randomised controlled trial (Randomised Evaluation of an Algorithm for Crohn's Treatment, REACT), we included community gastroenterology practices from Belgium and Canada that were willing to be assigned to either of the study groups, participate in all aspects of the study, and provide data on up to 60 patients with Crohn's disease. These practices were randomly assigned (1:1) to either ECI or conventional management. The computer-generated randomisation was minimised by country and practice size. Up to 60 consecutive adult patients were assessed within practices. Patients who were aged 18 years or older; documented to have Crohn's disease; able to speak or understand English, French, or Dutch; able to access a telephone; and able to provide written informed consent were followed up for 2 years. The primary outcome was the proportion of patients in corticosteroid-free remission (Harvey-Bradshaw Index score ≤ 4) at 12 months at the practice level. This trial is registered with ClinicalTrials.gov, number NCT01030809. FINDINGS: This study took place between March 15, 2010, and Oct 1, 2013. Of the 60 practices screened, 41 were randomly assigned to eitherECI (n=22) or conventional management (n=19). Two practices (one in each group) discontinued because of insufficient resources. 921 (85%) of the 1084 patients at ECI practices and 806 (90%) of 898 patients at conventional management practices completed 12 months follow-up and were included in an intention-to-treat analysis. The 12 month practice-level remission rates were similar at ECI and conventional management practices (66·0% [SD 14·0] and 61·9% [16·9]; adjusted difference 2·5%, 95% CI -5·2% to 10·2%, p=0·5169). The 24 month patient-level composite rate of major adverse outcomes defined as occurrence of surgery, hospital admission, or serious disease-related complications was lower at ECI practices than at conventional management practices (27·7% and 35·1%, absolute difference [AD] 7·3%, hazard ratio [HR]: 0·73, 95% CI 0·62 to 0·86, p=0·0003). There were no differences in serious drug-related adverse events. INTERPRETATION: Although ECI was not more effective than conventional management for controlling Crohn's disease symptoms, the risk of major adverse outcomes was lower. The latter finding should be considered hypothesis-generating for future trials. ECI was not associated with an increased risk of serious drug-related adverse events or mortality. FUNDING: AbbVie Pharmaceuticals.
RCT Entities:
BACKGROUND: Conventional management of Crohn's disease features incremental use of therapies. However, early combined immunosuppression (ECI), with a TNF antagonist and antimetabolite might be a more effective strategy. We compared the efficacy of ECI with that of conventional management for treatment of Crohn's disease. METHODS: In this open-label cluster randomised controlled trial (Randomised Evaluation of an Algorithm for Crohn's Treatment, REACT), we included community gastroenterology practices from Belgium and Canada that were willing to be assigned to either of the study groups, participate in all aspects of the study, and provide data on up to 60 patients with Crohn's disease. These practices were randomly assigned (1:1) to either ECI or conventional management. The computer-generated randomisation was minimised by country and practice size. Up to 60 consecutive adult patients were assessed within practices. Patients who were aged 18 years or older; documented to have Crohn's disease; able to speak or understand English, French, or Dutch; able to access a telephone; and able to provide written informed consent were followed up for 2 years. The primary outcome was the proportion of patients in corticosteroid-free remission (Harvey-Bradshaw Index score ≤ 4) at 12 months at the practice level. This trial is registered with ClinicalTrials.gov, number NCT01030809. FINDINGS: This study took place between March 15, 2010, and Oct 1, 2013. Of the 60 practices screened, 41 were randomly assigned to either ECI (n=22) or conventional management (n=19). Two practices (one in each group) discontinued because of insufficient resources. 921 (85%) of the 1084 patients at ECI practices and 806 (90%) of 898 patients at conventional management practices completed 12 months follow-up and were included in an intention-to-treat analysis. The 12 month practice-level remission rates were similar at ECI and conventional management practices (66·0% [SD 14·0] and 61·9% [16·9]; adjusted difference 2·5%, 95% CI -5·2% to 10·2%, p=0·5169). The 24 month patient-level composite rate of major adverse outcomes defined as occurrence of surgery, hospital admission, or serious disease-related complications was lower at ECI practices than at conventional management practices (27·7% and 35·1%, absolute difference [AD] 7·3%, hazard ratio [HR]: 0·73, 95% CI 0·62 to 0·86, p=0·0003). There were no differences in serious drug-related adverse events. INTERPRETATION: Although ECI was not more effective than conventional management for controlling Crohn's disease symptoms, the risk of major adverse outcomes was lower. The latter finding should be considered hypothesis-generating for future trials. ECI was not associated with an increased risk of serious drug-related adverse events or mortality. FUNDING: AbbVie Pharmaceuticals.
Authors: Christopher Ma; Carla Ascoytia; Kelly P McCarrier; Mona Martin; Brian G Feagan; Vipul Jairath Journal: Dig Dis Sci Date: 2018-06-29 Impact factor: 3.199
Authors: Christopher Ma; Matthew K Smith; Leonardo Guizzetti; Remo Panaccione; Gilaad G Kaplan; Kerri L Novak; Cathy Lu; Reena Khanna; Brian G Feagan; Siddharth Singh; Vipul Jairath; Ashwin N Ananthakrishnan Journal: Clin Gastroenterol Hepatol Date: 2020-01-25 Impact factor: 11.382
Authors: Gottfried Novacek; Hans Peter Gröchenig; Thomas Haas; Heimo Wenzl; Pius Steiner; Robert Koch; Thomas Feichtenschlager; Gerald Eckhardt; Andreas Mayer; Andreas Kirchgatterer; Othmar Ludwiczek; Reingard Platzer; Pavol Papay; Johanna Gartner; Harry Fuchssteiner; Wolfgang Miehsler; Paul-Gerhard Peters; Gerhard Reicht; Harald Vogelsang; Clemens Dejaco; Thomas Waldhör Journal: Wien Klin Wochenschr Date: 2019-02-04 Impact factor: 1.704
Authors: Siddharth Singh; Larry W Stitt; Guangyong Zou; Reena Khanna; Parambir S Dulai; William J Sandborn; Brian G Feagan; Vipul Jairath Journal: Aliment Pharmacol Ther Date: 2019-03-19 Impact factor: 8.171