Prophylactic medication for the prevention of endoscopic recurrence in Crohn's disease: a prospective study based on clinical risk stratification

Arkenbosch, J.H.C.; Beelen, E.M.J.; Dijkstra, G.; Romberg-Camps, M.; Duijvestein, M.; Hoentjen, F.; Marel, S. van der; Maljaars, P.W.J.; Jansen, S.; Boer, N.K.H. de; West, R.L.; Horjus, C.S.; Stassen, L.P.S.; Schaik, F.D.M. van; Ruler, O. van; Jharap, B.J.H.; Visschedijk, M.; Janssen, A.; Erler, N.S.; Doukas, M.; Ooms, A.H.A.G.; Kats-Ugurlu, G.; Woude, C.J. van der; Vries, A.C. de; Dutch Initiative Crohns Colitis IC

doi:doi:10.1093/ecco-jcc/jjac128

Background

To prevent recurrence after ileocolonic resection [ICR] in Crohn’s disease [CD], postoperative prophylaxis based on risk stratification is recommended in international guidelines. This study aimed to evaluate postoperative CD recurrence after implementation of a clinical management algorithm and to determine the predictive value of clinical and histological risk factors [RFs].

Methods

In this multicentre, prospective cohort study, CD patients [≥16 years] scheduled for ICR were included. The algorithm advised no postoperative medication for low-risk patients, and treatment with prophylaxis [immunosuppressant/biological] for high-risk patients [≥1 RF: active smoking, penetrating disease, prior ICR]. Clinical and histological RFs [active inflammation, granulomas, plexitis in resection margins] for endoscopic recurrence [Rutgeerts’ score ≥i2b at 6 months] were assessed using logistic regression and ROC curves based on predicted...

Background

To prevent recurrence after ileocolonic resection [ICR] in Crohn’s disease [CD], postoperative prophylaxis based on risk stratification is recommended in international guidelines. This study aimed to evaluate postoperative CD recurrence after implementation of a clinical management algorithm and to determine the predictive value of clinical and histological risk factors [RFs].

Methods

In this multicentre, prospective cohort study, CD patients [≥16 years] scheduled for ICR were included. The algorithm advised no postoperative medication for low-risk patients, and treatment with prophylaxis [immunosuppressant/biological] for high-risk patients [≥1 RF: active smoking, penetrating disease, prior ICR]. Clinical and histological RFs [active inflammation, granulomas, plexitis in resection margins] for endoscopic recurrence [Rutgeerts’ score ≥i2b at 6 months] were assessed using logistic regression and ROC curves based on predicted probabilities.

Results

In total, 213 CD patients after ICR were included [age 34.5 years; 65% women] (93 [44%] low-risk; 120 [56%] high-risk: 45 [38%] smoking; 51 [43%] penetrating disease; 51 [43%] prior ICR). Adherence to the algorithm was 82% in low-risk [no prophylaxis] and 51% in high-risk patients [prophylaxis]. Endoscopic recurrence was higher in patients treated without prophylaxis than with prophylaxis in both low [45% vs 16%, p = 0.012] and high-risk patients [49% vs 26%, p = 0.019]. Clinical risk stratification including the prescription of prophylaxis corresponded to an area under the curve [AUC] of 0.70 (95% confidence interval [CI] 0.61–0.79). Clinical RFs combined with histological RFs increased the AUC to 0.73 [95% CI 0.64–0.81].

Conclusion

Adherence to this management algorithm is 65%. Prophylactic medication after ICR prevents endoscopic recurrence in low- and high-risk patients. Clinical risk stratification has an acceptable predictive value, but further refinement is needed.

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Prophylactic medication for the prevention of endoscopic recurrence in Crohn's disease: a prospective study based on clinical risk stratification