title: Systematic review with meta-analysis: comparative efficacy of immunosuppressants and biologics for reducing hospitalisation and surgery in Crohn's disease and ulcerative colitis.
abstract: Crohn's disease (CD) and ulcerative colitis (UC) have a progressive course leading to hospitalisation and surgery. The ability of existing therapies to alter disease course is not clearly defined.
  
  
  
  To investigate the comparative efficacy of currently available inflammatory bowel disease (IBD) therapies to reduce hospitalisation and surgery.
  
  
  
  We conducted a systematic review in MEDLINE/PubMed for randomised controlled trials (RCT) published between January 1980 and May 2016 examining efficacy of biological or immunomodulator therapy in IBD. We performed direct comparisons of pooled proportions of hospitalisation and surgery. Pair-wise comparisons using a random-effects Bayesian network meta-analysis were performed to assess comparative efficacy of different treatments.
  
  
  
  We identified seven randomised controlled trials (5 CD; 2 UC) comparing three biologics and one immunomodulator with placebo. In CD, anti-TNF biologics significantly reduced hospitalisation [Odds ratio (OR) 0.46, 95% confidence interval (CI) 0.36-0.60] and surgery (OR 0.23, 95% CI 0.13-0.42) compared to placebo. No statistically significant reduction was noted with azathioprine or vedolizumab. Azathioprine was inferior to both infliximab and adalimumab in preventing CD-related hospitalisation (>97.5% probability). Anti-TNF biologics significantly reduced hospitalisation (OR 0.48, 95% CI 0.29-0.80) and surgery (OR 0.67, 95% CI 0.46-0.97) in UC. There were no statistically significant differences in the pair-wise comparisons between active treatments.
  
  
  
  In CD and UC, anti-TNF biologics are efficacious in reducing the odds of hospitalisation by half and surgery by 33-77%. Azathioprine and vedolizumab were not associated with a similar improvement, but robust conclusions may be limited due to paucity of RCTs.
authors.affiliation: Division of Gastroenterology, Alpert Medical School of Brown University, Providence, RI, USA.
authors.forename: E J
authors.initials: EJ
authors.lastname: Mao
authors.affiliation: Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada.|McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada.
authors.forename: G S
authors.initials: GS
authors.lastname: Hazlewood
authors.affiliation: Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada.
authors.forename: G G
authors.initials: GG
authors.lastname: Kaplan
authors.affiliation: Inserm U954 and Department of Gastroenterology, Nancy University Hospital, Université de Lorraine, Vandoeuvre, France.
authors.forename: L
authors.initials: L
authors.lastname: Peyrin-Biroulet
authors.affiliation: Gastroenterology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: A N
authors.initials: AN
authors.lastname: Ananthakrishnan
mesh_terms: D001688:Biological Products / Q000627:therapeutic use*; D003093:Colitis, Ulcerative / Q000175:diagnosis / Q000188:drug therapy* / Q000601:surgery; D003424:Crohn Disease / Q000175:diagnosis / Q000188:drug therapy* / Q000601:surgery; D006760:Hospitalization / Q000639:trends*; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D016032:Randomized Controlled Trials as Topic / Q000379:methods; D016896:Treatment Outcome
chemical_list: D001688:Biological Products; D007166:Immunosuppressive Agents