In Treating Crohn’s Disease, Earlier is Better

Patients receiving medical therapies when they have more complicated stages of Crohn’s disease (CD) are more likely to require surgery, researchers report in the March issue of Clinical Gastroenterology and Hepatology. The disease is most-effectively treated by drugs at its early, inflammatory stages.

Patients have a 40%–71% risk for requiring intestinal surgery within 10 years of diagnosis of Crohn’s disease. Although many drugs are used to treat this disease, there is controversy over their ability to reduce patients’ need for surgery.

Gordon Moran et al. investigated whether types of Crohn’s disease that patients have when they begin treatment with thiopurines (azathioprine or mercaptopurine) or anti-tumor necrosis factor (TNF) agents affect their need for surgery.

Moran et al. associated the presence of stricturing disease, ileal location, or ileocolonic location at the time patients are first prescribed thiopurines with a need for surgery. However, thiopurines were found to be more likely than other drugs to prevent the need for surgery for patients with only Crohn’s colitis.

Stricturing or penetrating disease at the time of prescription of anti-TNF agents was significantly associated with a need for surgery. Prescription of an anti-TNF agent after prescription of a thiopurine reduced the risk for surgery, compared with prescription of only a thiopurine.

Moran et al. conclude that treatment of Crohn’s disease with thiopurines and/or anti-TNF therapies before the development of complications reduces the risk for surgery. Treatment with these drugs after the development of complicated disease is not as effective—patients are more likely to require intestinal resection. Moran et al. state that the best outcomes are achieved when patients are treated at the early, inflammatory stage of disease development.

Interestingly, surgery before drug prescription reduced the risk for further surgeries among patients who received thiopurines or anti-TNF agents. Moran et al. say that there is evidence that the drugs can be effective after the disease course is reset by surgery.

Moran et al. acknowledge that physicians often face the challenge of whether to begin anti-TNF therapy after a complication develops, or to recommend surgery. The authors say that anti-TNF therapy can reduce the inflammatory component of a strictured segment and thereby prevent the need for surgery, or at least reduce the amount of surgery required. Residual inflammation before surgery has been associated with an increased incidence of complications after surgery.

The authors explain that treating patients at a late stage reduces drug efficacy, alters the risk–benefit ratio, and can be more expensive.

In a separate article in the March issue of CGH, Jean–Frédéric Colombel et al. report that among patients with moderate to severe ileocolonic Crohn’s disease who received the anti-TNF agent adalimumab as induction and maintenance therapy, those who achieved ‘deep remission’ (the absence of mucosal ulceration and CD Activity Index scores less than 150) appeared to have better 1-year outcomes (fewer hospitalizations and surgeries, lower rates of dosage adjustment, better quality of life, to be more productive and active, and have lower medical costs) than those who did not.

Similar to the findings of Moran et al., Colombel et al. say that anti-TNF agent therapy earlier in the disease course increases the probability of deep remission.