A comparative analysis of corticosteroids and exclusive enteral nutrition induction therapy in children with small bowel Crohn's disease: results of two prospective cohorts.

Corticosteroids (CS) and exclusive enteral nutrition (EEN) are effective induction therapies for pediatric Crohn's disease (CD), but comparative studies evaluating long-term outcomes in small bowel CD are lacking. Children (2-18 years) with newly diagnosed small bowel CD involving the ileum prospectively enrolled in the multicenter Canadian CIDsCaNN or European PIBD-SETQuality inception cohorts receiving CS or EEN induction treatment were evaluated longitudinally. The primary outcome was sustained steroid-free remission (SSFR) at 1 year. Secondary outcomes included changes in height z-scores, time-to-first-biologic and time-to-luminal-resection. Results were confirmed after propensity score matching (PSM). In total, 208 children (61% CIDsCaNN, 39% PIBD-SETQuality) treated with CS (n = 60) or EEN (n = 148) were eligible for analysis. Baseline clinical characteristics were comparable. Immunomodulator monotherapy and anti-TNF-based regimens were implemented as maintenance therapy in 64% and 22%, respectively, following EEN induction and in 75% and 15% following CS induction (p = 0.51). At 1 year, SSFR was achieved in 48% [23/48] in CS vs. 37% [46/124] in EEN (p = 0.19). Delta height z-scores at 1 year were comparable (- 0.05 [IQR - 0.23 to 0.21] with CS vs. + 0.01 [IQR - 0.18 to 0.25] with EEN, p = 0.26). Time to first biologic (39% [CS] vs. 50% [EEN] at 1 year) and time to luminal resection (6% [CS] vs. 11% [EEN] at 1 year) were similar. In the PSM cohort of 114 children (75 EEN, 39 CS), the RR (95% CI) for SSFR with CS (1.46 [0.86-2.49]) was comparable to that of the unmatched cohort (1.29 [0.89-1.88]).

conclusionsCS and EEN induction therapy demonstrate comparable effectiveness in pediatric small bowel CD, supporting the importance of shared decision-making.

trial registrationThe PIBD-SETQuality inception cohort was registered under trial registration number NCT03571373 (clinicaltrials.gov). The CIDsCaNN Network was registered under trial registration number NCT02308917 (clinicaltrials.gov). WHAT IS KNOWN: • Studies suggested better efficacy of exclusive enteral nutrition (EEN) in small bowel CD than colonic CD, and it is thought to favor growth, making it the preferred treatment option by physicians for small bowel CD. WHAT IS NEW: • This research demonstrated that both therapies are equally effective in achieving long-term outcomes, including sustained remission, growth, time to surgery or biologics, when followed by maintenance therapy.