The role of thiopurines in reducing the need for surgical resection in Crohn's disease: a systematic review and meta-analysis

Am J Gastroenterol. 2014 Jan;109(1):23-34; quiz 35. doi: 10.1038/ajg.2013.402. Epub 2013 Dec 10.


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.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Azathioprine / administration & dosage*
  • Confidence Intervals
  • Crohn Disease* / drug therapy
  • Crohn Disease* / epidemiology
  • Crohn Disease* / surgery
  • Digestive System Surgical Procedures / statistics & numerical data*
  • Disease Management
  • Humans
  • Immunosuppressive Agents / administration & dosage
  • Mercaptopurine / administration & dosage*
  • Observational Studies as Topic
  • Organ Sparing Treatments / methods
  • Outcome Assessment, Health Care
  • Proportional Hazards Models
  • Remission Induction / methods
  • Retrospective Studies
  • Risk Assessment


  • Immunosuppressive Agents
  • Mercaptopurine
  • Azathioprine