Strategies for the Prevention of Postoperative Recurrence in Crohn's Disease: Results of a Decision Analysis
Strategies for the Prevention of Postoperative Recurrence in Crohn's Disease: Results of a Decision Analysis
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DOI：
10.1038/ajg.2011.237
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发表时间：
2011-11-01
影响因子：
9.8
通讯作者：
Korzenik, Joshua R.
中科院分区：
文献类型：
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作者：
Ananthakrishnan, Ashwin N.;Hur, Chin;Korzenik, Joshua R.
目的：近70%的克罗恩病(CD)患者接受手术切除，四分之一的患者随后在12个月内出现临床复发。CD术后复发的预防有几种选择，但这些相互竞争的策略的比较成本效果之前还没有被分析过。方法：我们开发了一个决策分析模型，包括五种策略-无治疗、硫唑嘌呤(AZA)、抗生素(ABX)、先期英夫利昔单抗(IFX)，以及量身定制的IFX，包括在6个月后严重内窥镜复发的患者不进行预先治疗并开始使用IFX。基础病例1年的临床复发率为24%，AZA、ABX和IFX的复发率分别降低了41%、77%和99%。结果：在基础病例分析中，ABX(0.82个质量调整寿命年)和AZA(0.81个QALYs)方案比非治疗策略(0.80个QALYs)更有效且成本更低。最有效的策略是预付IFX(0.83 QALY)；然而，这也是最昂贵的，与不治疗相比，导致较高的增量成本-效果比(ICER)(777,732美元/QALY)。量身定制的IFX ARM不如预先使用有效，但ICER更可接受。在将复发率提高到78%(高危患者)方面，与不治疗相比，预先给予IFX可增加0.07个QALY(ICER为130,580美元/QALY)，而ABX、AZA和定制IFX ARM在不治疗中占主导地位。结论：抗生素是预防术后复发的最具成本效益的选择，但它们与较高的不耐受率有关，阻碍了广泛应用。前期IFX是最有效的策略，但即使在高危患者中也不具有成本效益。在所有患者中，保留IFX用于早期内窥镜复发的高危患者比预先使用更具成本效益。
OBJECTIVES: Nearly 70% of patients with Crohn's disease (CD) undergo surgical resection, with one-quarter subsequently developing clinical recurrence within 12 months. Several options exist for the prevention of postoperative recurrence in CD, but the comparative cost effectiveness of these competing strategies has not been previously analyzed.METHODS: We developed a decision analytic model comprising five strategies-No Treatment, azathioprine (AZA), antibiotics(ABX), upfront infliximab(IFX), and tailored IFX that consisted of no upfront therapy with initiation of IFX in patients with severe endoscopic recurrence at 6 months. The base-case 1-year clinical recurrence rate was 24% with reduction in recurrence by 41%, 77%, and 99% for AZA, ABX, and IFX, respectively. A 1-year time horizon was used and sensitivity analyses were performed.RESULTS: At the base-case analysis, the ABX (0.82 quality-adjusted life years (QALYs)) and AZA (0.81 QALYs) arms were more effective and less expensive than the No Treatment strategy (0.80 QALYs). The most effective strategy was upfront IFX (0.83 QALYs); however, this was also the most expensive and resulted in a high incremental cost-effectiveness ratio (ICER) ($777,732/QALY) compared with no treatment. The tailored IFX arm was less effective than upfront use but had a more acceptable ICER. On increasing the recurrence rate to 78% (high-risk patients), upfront IFX resulted in 0.07 QALYs (ICER $130,580/QALY) gained compared with No Treatment, whereas ABX, AZA, and tailored IFX arms dominated No Treatment.CONCLUSION: Antibiotics are the most cost-effective option for preventing postoperative recurrence, but they have been associated with high rates of intolerance precluding widespread use. Upfront IFX is the most efficacious strategy but is not cost effective even in high-risk patients. Reserving IFX use for high-risk patients with early endoscopic recurrence is more cost effective than upfront use in all patients.