title: Infliximab "Top-Down" Strategy is Superior to "Step-Up" in Maintaining Long-Term Remission in the Treatment of Pediatric Crohn Disease.
abstract: OBJECTIVE
  We aimed to compare the efficacy of remission maintenance between infliximab "top-down" and "step-up" strategies in moderate to severe pediatric Crohn disease during 3 years. We also aimed to determine prognostic factors that may influence the relapse-free rate in these patients.
  
  
  METHODS
  The present study was a retrospective review of a prospective cohort, based on an infliximab treatment protocol for pediatric Crohn disease used at Samsung Medical Center. A total of 31 patients (group A) were treated with early infliximab induction ("top-down" strategy) and 20 patients (group B) refractory to conventional therapy underwent infliximab treatment ("step-up" strategy). The efficacy of infliximab treatment was assessed by relapse-free rate and remission period rate for 3 years. A total of 11 prognostic factors that may influence the relapse-free rate were further analyzed.
  
  
  RESULTS
  The relapse-free rates at 3 years were 35.5% (95% confidence interval [CI] 0.194-0.519) in group A and 15.0% (95% CI 0.037-0.335) in group B (P = 0.0094). Overall remission period rate for 3 years also showed a significant difference between the 2 groups (92.1%  ± 7.2% vs 78.3%  ± 16.6%; P = 0.005). Multivariable analysis revealed that the duration from the initial diagnosis to infliximab infusion was the only factor associated with relapse-free remission for 3 years (hazard ratio = 1.077; 95% CI 1.025-1.131).
  
  
  CONCLUSIONS
  "Top-down" strategy had a longer remission period compared with the "step-up" strategy in pediatric Crohn disease during a study period of 3 years, based on relapse-free rate and remission period rate. Earlier introduction of infliximab is recommended in pediatric patients with moderate to severe Crohn disease.
authors.affiliation: *Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine †Department of Pediatrics, Korea University Anam Hospital, Korea University College of Medicine, Seoul ‡Department of Pediatrics, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, South Korea.
authors.forename: Yoo Min
authors.initials: YM
authors.lastname: Lee
authors.forename: Ben
authors.initials: B
authors.lastname: Kang
authors.forename: Yoon
authors.initials: Y
authors.lastname: Lee
authors.forename: Mi Jin
authors.initials: MJ
authors.lastname: Kim
authors.forename: Yon Ho
authors.initials: YH
authors.lastname: Choe
mesh_terms: D000293:Adolescent; D000911:Antibodies, Monoclonal / Q000008:administration & dosage / Q000627:therapeutic use; D002648:Child; D003424:Crohn Disease / Q000175:diagnosis / Q000188:drug therapy* / Q000503:physiopathology*; D018572:Disease-Free Survival; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D000069285:Infliximab / Q000008:administration & dosage* / Q000627:therapeutic use*; D008297:Male; D015999:Multivariate Analysis; D011379:Prognosis; D012008:Recurrence; D012074:Remission Induction; D012189:Retrospective Studies; D012720:Severity of Illness Index; D016896:Treatment Outcome
chemical_list: D000911:Antibodies, Monoclonal; D000069285:Infliximab