This prospective, multicenter inception cohort study (BISCUIT) evaluated the impact of early 5-ASA monotherapy (within 90 days of diagnosis) vs. biologics, immunomodulators, or no therapy on biologic durability, corticosteroid exposure, and disease complications in 679 pediatric Crohn's disease patients.
18% of patients received early 5-ASA monotherapy; this group had greater systemic corticosteroid use (p=0.036), delayed time-to-biologic (~11 months median), and — among those who escalated — a 4.47-fold higher risk of biologic discontinuation (HR 4.47 [95% CI 1.28–15.65]; p=0.029). Early anti-TNF therapy protected against perianal disease (OR 0.24 [0.06–0.93]; p=0.039), while 5-ASA and immunomodulators did not.
- Observational design with potential for residual confounding despite inverse probability weighting. - Relatively small subgroup who received early 5-ASA and subsequently escalated to biologics, widening confidence intervals. - Generalizability may be limited to centers participating in the BISCUIT multicenter cohort.
Avoid 5-ASA in newly diagnosed pediatric Crohn's disease — it delays effective therapy and worsens biologic durability without preventing complications. Prioritize early anti-TNF therapy, which reduces perianal disease risk.
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