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Top Down Therapy vs Step Up Therapy in Pediatric Patients with new onset Crohn’s Disease

Top Down Therapy vs Step Up Therapy in Pediatric Patients with new onset Crohn’s Disease. Presenters Dr Ali Minhas M.B.B.S Dr Orooj Khan M.B.B.S Mentor Dr Maya D Srivastava M.D. Background.

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Top Down Therapy vs Step Up Therapy in Pediatric Patients with new onset Crohn’s Disease

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  1. Top Down Therapy vs Step Up Therapy in Pediatric Patients with new onset Crohn’s Disease Presenters Dr Ali Minhas M.B.B.S Dr Orooj Khan M.B.B.S Mentor Dr Maya D Srivastava M.D

  2. Background • Top-down (TD) therapy with tumor necrosis factor inhibitors early in disease course of adult Crohn's disease (CD) has been shown to result in decreased steroid dependence, hospitalizations, complications, and disease activity compared to conventional step-up (SU) therapy

  3. Background • Anti-TNF is effective in pediatric patients with CD failing conventional step up therapy • Data regarding Top Down therapy in pediatric patients is limited

  4. Introduction Aim • To compare top down therapy with step up therapy in relation to achieving early remission and prevention of known disease complications in pediatric patients with new onset Crohn’s Disease

  5. Introduction Top Down Therapy • Inclusion of biologic agents as initiation therapy to alter the course of Crohn’s disease Step Up Therapy • Use of least efficacious to most potent agents in a step wise fashion to alter the course of Crohn’s Disease

  6. Crohn’s Disease Management Pyramids Step Up Therapy Top Down Therapy

  7. Study Design • Retrospective chart review of all pediatric patients (age under 18) with CD in an outpatient solo practice • Charts reviewed dated from 2007-2009 • 89 charts identified by diagnostic billing codes for CD (555.0, 555.1, 555.2) • 21 patients satisfied the inclusion criteria and all were included in the study

  8. Study Design • Crohn’s Disease Activity Index (CDAI) used to calculate the severity of CD • Data analysis conducted by using unpaired t test and Fischer’s exact test • IRB exempt

  9. Crohn’s Disease Activity Index

  10. Crohn’s Disease Activity Index Scoring System • Mild Disease 150-199 • Moderate Disease 200-449 • Severe Disease >450 • Remission <150

  11. Baseline Demographics

  12. Grouping

  13. Results

  14. Primary End Point

  15. Primary End Point

  16. Results

  17. Complications of Disease on Therapy

  18. Secondary End Points

  19. Conclusions • TD strategy is more effective in rapidly gaining and maintaining control in the first year of diagnosis in pediatric patients with new onset Crohn’s disease • TD therapy associated with decreased complications of disease, relapses and steroid dependence in the first year of diagnosis

  20. Conclusions • Almost all patients on step up therapy relapsed in the first year and required anti-TNF salvage

  21. Study Evaluation • Small sample size • Retrospective study • Insurance Approval Barriers

  22. Thank You

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