Treatment of Inflammatory Bowel Disease with Biologics

73

appears as efficacious as immediate initiation postoperatively and may reduce
costs and side effects. However, nearly half of patients within the active care arm
still had endoscopic recurrence at 18 months post-resection, suggestive of a con-
tinued unmet need in the treatment of POR.

Practical Strategies for Treating Postoperative Recurrence

There are two emerging strategies to postoperative CD management. One strategy,
in alignment with the POCER study methods, would be to stratify postoperative
treatment based on risk of recurrence and treat high-risk patients (smokers, perforat-
ing disease, or prior CD resection) with thiopurine or anti-TNF if intolerant of thio-
purines (Fig. 5.1). Patients should then undergo early (at 6–12  months)
ileocolonoscopy with escalation of medical care for endoscopic (≥i2) recurrence.
Untreated patients would be started on thiopurine therapy, and patients receiving
thiopurines would be advanced to anti-TNF therapy or increased dosing of anti-
TNF therapy.
The second strategy (and the authors’ practice) is to start prophylactic treatment
for high- and moderate-risk patients (Fig. 5.2). Those at low risk for recurrence
would not be started on postoperative medical POR prophylaxis. Low-risk patients
are those undergoing first CD-related surgery for short (<10 cm) stricture with long-
standing CD (>10 years). Patients at moderate risk include those undergoing first
CD-related surgery but with shorter disease duration (<10  years) with a longer
affected bowel segment (>10 cm). Moderate-risk patients would receive thiopurine

Risk Stratification

Low

Colonoscopy

6-12 months postop 6-12 months postopColonoscopy

Colonoscopy

every 1-3 years every 1-3 yearsColonoscopy

No Meds

+/- Metronidazole

No Recurrence No Recurrence

6-MP/AZA or

Anti-TNF

6-MP or AZA

+/- Metronidazole

Anti-TNF or

∆ Biologic

Recurrence Recurrence

Anti-TNF

AZA Navie

High

AZA Intolerant

Fig. 5.1 “Watchful waiting” algorithm for management of postoperative Crohn’s disease recur-
rence. High-risk patients include active smokers, those with perforating disease, or prior CD resec-
tion. Low risk includes all other patients

5 Use of Biologics in the Postoperative Management of Crohn’s Disease