Active management cuts recurrence after Crohn's surgery

Last Updated: 2015-01-19

By Anne Harding

NEW YORK (Reuters Health) - Early colonoscopy and treatment step-up as needed is more effective than standard drug therapy alone for preventing postoperative recurrence of Crohn's disease, new findings show.

Seventy percent of Crohn's patients will need surgical resection, and 30% will develop clinical recurrence within a year of surgery, according to a report by Dr. Michael A. Kamm of St. Vincent's Hospital in Melbourne, Victoria, Australia, and colleagues online December 24 in The Lancet.

Currently, Crohn's patients are treated "with a haphazard variety of drugs and monitoring" after surgery, Dr. Kamm told Reuters Health via email.

In the current study, 174 patients undergoing intestinal resection for Crohn's disease at 17 centers were randomly assigned to receive active treatment or standard care. All patients received three months of metronidazole therapy, and those considered to be at high risk of recurrence were given a thiopurine or adalimumab if they could not tolerate thiopurines.

The active treatment patients had a colonoscopy six months after surgery. Those who had endoscopic recurrence, defined as a Rutgeerts score of i2 or higher, were stepped-up to either thiopurine, adalimumab every two weeks plus thiopurine, or adalimumab weekly.

Eighty-three percent of patients in both groups were high-risk, meaning they had one or more of these risk factors: smoking, perforating disease, or previous surgery.

In the active care group, which included 122 patients, 39% stepped up treatment at six months. The study's primary outcome, endoscopic recurrence at 18 months, occurred in 49% of the active-care patients and 67% of the standard care group (p=0.03). Twenty-two percent of patients in the active group had "complete mucosal normality" throughout the study period, versus 8% of the standard care patients. (p=0.03).

Patients who either smoked or smoked and had at least one other risk factor were more likely to have endoscopic recurrence. The risk of adverse events was similar in the two groups.

"Proactive management after surgery decreases the chance of disease recurrence," Dr. Kamm told Reuters Health. He and his colleagues are currently investigating whether fecal testing can be used to monitor patients instead of colonoscopy, and also investigating which gut bacteria may be associated with disease recurrence.

His advice for doctors treating patients after Crohn's surgery: "Be proactive."

The trial "convincingly shows that an active strategy is associated with better outcomes in postoperative Crohn's disease; however, it poses many questions," Dr. Ashwin Ananthakrishnan of Harvard Medical School in Boston writes in an editorial.

For example, the editorial continues, "The rate of endoscopic recurrence at 18 months was high even in the active care arm and, for many treating physicians, a recurrence rate of 49% might be unacceptably high. Would earlier use of adalimumab in a population that had probably already shown loss of response to thiopurines have resulted in a lower rate of recurrence? Small preliminary trials and open-label case series of postoperative biologicals showed recurrence rates as low as 10% at one year."

SOURCE: http://bit.ly/17Zbcp0

Lancet 2014.