Medical Prophylaxis of Post-Surgical Crohn’s Disease Recurrence: Towards Timely Anti-TNF Therapy

Excerpt

Crohn’s disease typically affects the terminal ileum and proximal colon; approximately 50% of patients will require bowel resection due to penetrating disease or stricture within 10 years of disease diagnosis [1]. Intestinal resection for these patients is not curative with up to 90% of patients demonstrating endoscopic evidence of recurrence 1 year postoperatively [1]. Risk factors for Crohn’s disease recurrence after surgical therapy include cigarette smoking, younger age, penetrating disease, shorter duration of disease prior to resection, prior surgical resections, and ileocolic disease [2]. Antibiotics, thiopurines, and steroids all have variable efficacy in reducing postoperative recurrence. In 2009, Regueiro et al. [3] provided the first evidence that infliximab administered as a postoperative prophylactic therapy could reduce endoscopic, clinical, and histologic Crohn’s disease recurrence published as a proof-of-concept randomized trial. Although only 24 patients were included in this study, 9.1% of patients receiving infliximab within 4 weeks of surgery compared to 84.6% of patients receiving placebo had endoscopic recurrence at 1 year postoperatively. Subsequent trials have shown that the administration of anti-tumor necrosis factor (anti-TNF) agents several weeks postoperatively effectively reduces Crohn’s recurrence and anti-TNF agents are often superior to thiopurines [4, 5]. In 2017, the American Gastroenterological Association (AGA) published its guidelines on the management of Crohn’s disease after surgery [2] recommending anti-TNF therapy and/or thiopurines within 8 weeks of surgery as first-line pharmacological prophylaxis for disease recurrence. To date, there have been no studies assessing the percentage of high-risk Crohn’s patients actually receiving timely postoperative anti-TNF therapy and evaluating and analyzing the factors associated with delayed administration. …