Treatment of Inflammatory Bowel Disease with Biologics

74

therapy immediately after surgery. If a patient can tolerate metronidazole, this is
reasonable to combine with immunomodulator therapy given the increased benefit.
High-risk patients include perforating or penetrating disease, active smokers, and/or
patients with prior intestinal resection. Those at high risk would receive postopera-
tive combination therapy with thiopurines and an anti-TNF agent.
All patients regardless of risk would undergo colonoscopy at 6–12 months with
treatment escalation based on endoscopic findings of recurrence. Low-risk patients
would be initiated on therapy, likely with an immunomodulator. Moderate-risk
patients would be initiated on an anti-TNF agent with induction followed by main-
tenance dosing for anti-TNF-naïve patients. High-risk patients on postoperative
combination therapy with evidence of recurrent disease should have medications
optimized including drug and antibody levels with adjustments based on findings
and/or consider switching to alternative anti-TNF agent. It should be noted that
while commonly practiced, postoperative combination therapy with an anti-TNF
agent and a thiopurine has not been formally studied in prevention of postoperative
recurrence.
The timing of medication initiation in most clinical studies has generally been
within 2–4 weeks of surgery. This time period allows for adequate identification and
treatment of most postoperative infectious complications.
Comparing these two strategies—early postoperative medical prophylaxis and
endoscopy-guided therapy—was studied by Ferrante and colleagues. The authors
performed a randomized controlled trial of 63 CD patients randomized to either
routine early postoperative weight-based AZA within 2 weeks of surgery (n = 32) or

Risk Stratification

Low

Colonoscopy

6-12 months postop

Colonoscopy

6-12 months postop

Colonoscopy

every 1-3 years every 1-3 yearsColonoscopy

No Meds

No Recurrence No Recurrence

6-MP/AZA or

Anti-TNF

6-MP or AZA

+/- Metronidazole

Anti-TNF or

∆ Biologic

Recurrence Recurrence

Moderate High

Anti-TNF + 6-MP/AZA

Fig. 5.2 Postoperative prophylaxis for all patients but low-risk paradigm for prevention of post-
operative Crohn’s disease recurrence. Low-risk patients are those undergoing first CD-related sur-
gery 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). High-risk patients include perforating or penetrat-
ing disease, active smokers, and/or patients with prior intestinal resection

B.H. Click and M. Regueiro