Anti-TNF Best at Preventing Postsurgery Relapse in Crohn's

Lara C. Pullen, PhD

January 06, 2015

Postoperative prophylaxis with anti–tumor necrosis factor-α (anti-TNF) monotherapy appears to be the most effective option after surgical resection for Crohn's disease (CD). The conclusion is based on moderate- to high-quality evidence gleaned from a systemic review.

Siddharth Singh, MD, from the Division of Gastroenterology and Hepatology at the Mayo Clinic in Rochester, Minnesota, and colleagues published the results of their systematic review online September 25, 2014, and in the January 2015 issue of Gastroenterology. The team assessed the relative efficacy of all available agents used for postoperative prophylaxis after surgical resection in patients with CD. Their systematic search included literature published through March 2014.

The authors found 21 trials comparing seven treatment strategies used for 2006 participants. They identified only three randomized control trials that compared anti-TNF monotherapy with placebo or other active agents, such as an immunomodulator or mesalamine. The authors note that most of the studies defined clinical relapse based on Crohn's Disease Activity Index (CDAI), but explain that CDAI is a poor predictor of clinical recurrence.

A Bayesian network meta-analysis revealed that anti-TNF monotherapy, when compared with placebo, significantly reduced the risk for clinical relapse (relative risk, 0.04; 95% credible interval, 0.00 - 0.14).

Choosing the Best Treatment

Many patients with CD experience endoscopic and clinical relapse after surgical resection. Recurrence is an important problem, and patients are frequently prescribed medical therapy to minimize the risk. Both mesalamine and immunomodulator monotherapy have been shown in randomized clinical trials to prevent relapse after surgically induced remission for CD.

The current meta-analysis indicates that immunosuppressive agents, biologic agents, antibiotics, and, to a lesser extent, aminosalicylates decrease the risk for recurrence. In contrast, use of the corticosteroid budesonide was not associated with a reduction of CD recurrence.

Biologic agents were the most effective at reducing the risk for disease recurrence. The authors thus suggest that patients at high risk for postoperative occurrence be considered for biologic agents.

Patients at moderate risk for disease recurrence may be best suited for antibiotics or immunosuppressive medications. The moderate-risk category would include patients with intermediate-duration inflammatory CD.

A patient at low risk for recurrence may be find aminosalicylates to be sufficient. The authors add that a cost–utility analysis would aid in the individualization of a strategy for postoperative prophylaxis.

"The most surprising finding is that there were only 21 studies examined. This problem is very important, but has not been adequately addressed with randomized clinical trials. For example, there is only one small study comparing infliximab [anti-TNF] to placebo in the postoperative period," Bret Lashner, MD, from the Cleveland Clinic in Ohio, explained to Medscape Medical News. He also pointed out that a larger study of anti-TNF vs placebo is underway.

One author has consulted for and has received research support from Janssen Biotech, AbbVie, and UCB Pharma. The other authors and Dr Lashner have disclosed no relevant financial relationships.

Gastroenterology. 2015;148:64-76. Abstract

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