Pharmacologic Treatment Effective for Preventing Post-Operative Recurrence of Crohn Disease

Anti-tumor necrosis factor (TNF) agents and/or thiopurines are effective for the prevention of disease recurrence in patients with surgically induced remission of Crohn disease (CD), said Miguel Regueiro, MD, at the 2019 Advances in Inflammatory Bowel Diseases (AIBD) Meeting.

Dr Regueiro, from the Cleveland Clinic Lerner College of Medicine, shared the information during his Keynote Lecture on post-operative management of CD.¹ Patients who have ileocecal resection for CD experience deep remission, but histological recurrence after surgery can happen as early as 1 to 2 weeks. Active CD can be seen 1 year after surgery in the neoterminal ileum above the anastomosis. At this point, the recurrence is clinically silent and can only be detected via colonoscopy, he said. Later on, however, structural damage and symptoms of CD recur, and further resection is required.

While clinicians often take one of two approaches to the problem of preventing disease recurrence in post-operative patients—either starting treatment 2 to 3 weeks after surgery for prevention, or monitoring with colonoscopy as early as 6 months after surgery and starting treatment only if recurrence is detected—Dr Regueiro advised that the former strategy is preferable and is recommended by the American Gastroenterological Association Institute Guideline on the Management of Crohn’s Disease After Surgical Resection.²

A number of studies on the use of anti-TNF therapies have shown a trend of a roughly 20% endoscopic recurrence rate in patients on post-operative anti-TNF treatment, vs 50% with placebo. Infliximab and adalimumab have both demonstrated effectiveness, with no significant differences in prevention of recurrence. Thiopurines have also been shown to be effective. Dr Regueiro noted that, when looking at the data from these studies, it is important to compare the most and least severe groups of patients to best determine the clinical relevance of the outcome.

Studies have also supported the intensification of treatment upon the identification of disease recurrence by colonoscopy.

While questions remain about whether to initiate treatment before the detection of endoscopic recurrence, Dr Regueiro emphasized that it is important to continuously monitor patients for recurrence 6 to 12 months post-operatively with colonoscopy, and not to wait until clinical recurrence to begin pharmacologic therapy.

He also cautioned against the use of 5-aminosalicylate medications in this patient population; while there is no good data to support its use, it continues to be the most prescribed therapy after surgery for CD, he said.

—Kara Rosania

References:

1. Regueiro M. Keynote Speaker: 2020 management of post-operative CD: the road ahead. Presented at: 2019 AIBD Meeting; December 12-14, 2019; Orlando, FL.
2. Nguyen GC, Loftus EV Jr, Hirano I, et al; the AGA Institute Clinical Guidelines Committee. American Gastroenterological Association Institute guideline on the management of Crohn’s disease after surgical resection. Gastroenterology. 2017;152:271-275.