Abstract

Objectives Approximately 50% of patients with Crohn’s disease (CD) undergo surgery, and a significant proportion suffer from a post-surgical recurrence. We conducted a network meta-analysis to compare the efficacy of various interventions.

Design Systematic review and network meta-analysis.

Data sources MEDLINE, EMBASE and Cochrane Library were searched from inception up to February 2025.

Eligibility criteria Randomised controlled trials (RCTs), reported in any language, comparing treatments used for maintaining surgically induced remission in CD were included. The primary outcomes were clinical relapse, endoscopic relapse and withdrawal due to adverse events.

Data extraction and synthesis Two reviewers independently extracted data and assessed risk of bias. Certainty of evidence was rated with GRADE (Grading of Recommendations Assessment, Development and Evaluation), and SUCRA (surface under the cumulative ranking curve) was used to rank treatments.

Results There were 34 RCTs (n=3197). For clinical relapse, adalimumab reduced the risk of relapse compared with placebo (moderate certainty), risk ratio (RR) 0.31 (95% CI 0.16 to 0.60), moderate effect size. Two treatments may reduce the risk of clinical relapse (low certainty): 5-aminosalicylic acid (RR 0.79, 95% CI 0.66 to 0.94; trivial effect size) and purine analogues (RR 0.79, 95% CI 0.66 to 0.96; trivial effect size). All other treatments were of very low certainty. For endoscopic relapse, vedolizumab probably reduced the risk of relapse (moderate certainty), RR 0.37 (95% CI 0.17 to 0.80), large effect size. Adalimumab may reduce the risk of endoscopic relapse (low certainty), RR 0.47 (95% CI 0.27 to 0.80), large effect size. All other treatments were of very low certainty.

Conclusions Adalimumab and vedolizumab reduce endoscopic relapse with moderate to large effects supported by moderate to low certainty evidence. Adalimumab also prevents clinical relapse with moderate certainty. Other therapies either had evidence of trivial effect size or very low certainty evidence. Postoperative maintenance should be individualised based on patient risk and treatment profile.