Objective

Medication treatment strategies for Crohn’s disease (CD) include step-up (SU) therapy, which initiates with oral anti-inflammatory agents, and top-down (TD) therapy, which initiates with biologics or immunomodulators. The real-world utilization and short-term medical costs associated with these treatment strategies are not well described. This research examined the prevalence of TD therapy use over time and first-year direct medical expenditures among patients initiating CD medication treatment with SU as compared with TD therapy in a real-world setting.

Methods

We conducted a retrospective, cohort study of Optum Clinformatics® Data Mart examining patients with CD who were newly initiated on medication therapy from 2010 to 2018. A joinpoint regression was conducted to determine the statistical significance of differences in the use of TD and SU therapy over time. A generalized linear model was used to quantify the differences in adjusted mean first-year CD-specific, direct non-pharmacy medical costs between utilizers of TD and SU therapy.

Results

We identified 3,157 patients newly initiating medication therapy for CD: 2,392 (75.8%) patients treated with SU therapy and 765 (24.2%) treated with TD therapy. The use of TD therapy over the study period increased from 17% in 2011 to 31% in 2017. TD therapy was also associated with a 149.8% ($1,230) higher adjusted average per-patient first-year CD-direct medical costs compared with SU therapy (adjusted ratio of cost for TD compared to SU: 2.498, 95% CI: 2.12, 2.95).

Conclusion

In patients newly initiating medication therapy for CD, TD therapy use increased between 2010 and 2017 and was associated with higher first-year medical expenditure. These findings align with the strategy of initiating TD therapy in patients with a higher disease burden. Further research is needed to determine long-term overall healthcare costs and clinical outcomes associated with SU and TD strategies in a real-world setting.