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The Role of Thiopurines in Reducing the Need for Surgical Resection in Crohn's Disease: A Systematic Review and Meta-Analysis

Chatu, Sukhdev MD1; Subramanian, Venkataraman MD2; Saxena, Sonia MD3; Pollok, Richard CG FRCP, PhD1

American Journal of Gastroenterology: January 2014 - Volume 109 - Issue 1 - p 23–34
doi: 10.1038/ajg.2013.402

OBJECTIVES: The thiopurine (TP) analogs azathioprine and mercaptopurine have proven efficacy in inducing and maintaining clinical remission in Crohn's disease (CD). Their impact on the long-term need for surgery is uncertain since studies have reported conflicting results. The aim of this systematic review was to summarize and evaluate evidence of the published literature regarding those studies assessing the impact of TPs on the risk of first surgical resection in CD.

METHODS: We searched Medline, EMBASE, CINAHL, and hand searched reference lists of identified articles, without language restrictions in August 2013.

RESULTS: Seventeen retrospective observational studies (eight population based, three multicenter, and six referral center) representing 21,632 participants met our inclusion criteria. Of these 10 studies involving 12,586 participants provided data on the hazard ratio (HR) and 95% confidence intervals (CIs) evaluating use of TPs and surgical risk. The combined pooled HR of first intestinal resection with TP use was 0.59 (95% CI 0.48–0.73).

CONCLUSIONS: TP use is associated with a 40% lowered risk of surgical resection in patients with CD. Despite significant reductions in rates of surgical resection in patients with CD over the last 5 decades and increasing use of TPs, a large proportion of patients with CD still require resectional surgery.

1 Department of Gastroenterology, St George's University Hospital, London, UK

2 Center for Digestive Diseases, St James's University Hospital, Leeds, UK

3 Department of Primary Care and Public Health, Imperial College, London, UK

Correspondence: Richard C.G. Pollok, Department of Gastroenterology, St George's University Hospital, Blackshaw Road, London SW17 0QT, UK. E-mail:

Received 22 January 2013; accepted 1 October 2013

published online 10 December 2013

© The American College of Gastroenterology 2014. All Rights Reserved.
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