Is the Writing on the Wall? The Relationship Between the Number of Disease Modifying Anti-Inflammatory Bowel Disease Drugs Used and the Risk of Surgical Resection

Background Disease modifying drugs anti-inflammatory bowel disease drugs revolutionized the management of ulcerative colitis. This study assesses the relationship between the number and timing of drugs used to treat ulcerative colitis and the risk of colectomy and postoperative complications. Methods Retrospective review of adult patients with ulcerative colitis treated with disease-modifying drugs between 2005-2020 in the Marketscan database. Landmark and time-varying regression analyses were used to analyze risk of surgical resection. Multivariable Cox regression analysis was used to determine risk of postoperative complications, emergency room visits, and readmissions. Results 12193 patients with ulcerative colitis and treated with disease-modifying drugs were identified. With a median follow up time of 1.7 years, 23.8% utilized >1 drug, and 8.3% of patients required surgical resection. In landmark analyses, using 2 and ≥3 drugs prior to the landmark date was associated with higher incidence of surgery for each landmark compared to 1 drug. Multivariable Cox regression showed hazard ratio (95% CIs) of 4.22 (3.59-4.97), 11.7 (9.01-15.3), and 22.9 (15.0-34.9) for using 2, 3, and ≥4 drugs, respectively, compared to using 1 DMAID. That risk was constant overtime. Number of drugs utilized preoperatively was not associated with an increased postoperative risk of any complication, emergency room visits, or readmission. Conclusions Use of multiple disease-modifying drugs in ulcerative colitis is associated with an increased risk of surgical resection with each additional drug. This provides important prognostic data and highlights the importance of patient counseling with minimal concern regarding risk of postoperative morbidity for additional drugs.