Does Infliximab Worsen Strictures in Crohn's Disease?

Bret A. Lashner, MD

Disclosures

October 08, 2010

Question

Considering their cicatrizing properties, could anti-TNF agents indeed worsen strictures in patients with Crohn's disease?

Response from Bret A. Lashner, MD
Professor of Medicine, Cleveland Clinic, Cleveland, Ohi

Editor's Note: In August, a Medscape reader wrote in with the question, "Is Infliximab Appropriate for Stricturing-Type Crohn's Disease?" Gastroenterologist Bret A. Lashner, MD, responded to this question by explaining that in a patient with Crohn's disease with an intestinal stricture, before starting therapy with an anti-tumor necrosis factor (TNF) agent such as infliximab, the patient be studied and only receive an anti-TNF agent if inflammatory-type disease is documented. Patients with stricturing disease, who do not have an inflammatory component to their stricture, should have surgery.

This prompted a new question about the use of anti-TNF agents (such as infliximab) in patients with strictures. A reader asks, "Considering their cicatrizing properties, could anti-TNF agents indeed worsen strictures?" Dr. Lashner's response to this question is below.

Infliximab for patients with Crohn's disease works best when taken by patients who have inflammatory-type disease. Patients who have stricturing-type disease often do not do as well on anti-TNF agents; therefore, these patients are usually excluded from clinical trials. Because infliximab works so well to reduce inflammation, the fibrosis left behind after resolution of the inflammation can cause symptomatic stenosis, stricture, or obstruction (SSOs). This issue was studied using the TREAT (Crohn's Therapy, Resource, Evaluation, and Assessment Tool) registry, a manufacturer-maintained registry of 6290 patients with Crohn's disease in which about half of the patients were treated with infliximab and the rest were treated with alternative non-biologic anti-inflammatory agents.[1]The rate of SSOs in infliximab-treated patients was about twice as high as in controls (1.95 events/100 patient-years vs 0.99 events/100 patient-years). The adjusted odds ratio was 1.7 (meaning that infliximab-treated patients had a 70% higher rate of SSOs), but this effect was not statistically significant. Still, it is likely that infliximab, and other anti-TNF agents, induce stenosis and should be used with caution in patients with stricturing-type Crohn's disease. Also, patients with inflammatory-type Crohn's disease who have been successfully treated with infliximab should be carefully observed for the development of obstructive symptoms.

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