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Journal of Crohn's and Colitis: 10 (10)


Laurence J. Egan, Ireland

Associate Editors

Shomron Ben-Horin, IsraelSilvio Danese, ItalyPeter Lakatos, HungaryMiles Parkes, UKJesús Rivera-Nieves, USABritta Siegmund, GermanyGijs van den Brink, NLSéverine Vermeire, Belgium


Published on behalf of

Adalimumab or infliximab for the prevention or treatment of post-operative recurrence in Crohn's disease

Takayuki Yamamoto
DOI: http://dx.doi.org/10.1016/j.crohns.2012.09.011 e157 First published online: 1 May 2013

Dear Sir,

I read with interest the article by Papamichael et al., ‘Adalimumab (ADA) for the prevention and/or treatment of post-operative recurrence of Crohn's disease (CD): a prospective, two-year, single center, pilot study’.1 In their prospective, single-center, open-label study, 23 patients who had undergone ileocecal resection for CD were treated with ADA. Eight patients received ADA therapy starting from the 14th post-operative day for the prevention of recurrence (Group I). Fifteen patients started ADA therapy when endoscopic recurrence was confirmed at 6 months post-operatively despite treatment with azathioprine (AZA), infliximab (IFX) or mesalazine (Group II). All patients were followed up for two years. In Group I, 2 patients (25%) developed endoscopic recurrence, of whom one had clinical recurrence as well. In Group II, all patients had endoscopic recurrence whereas 9 patients (60%) had clinical recurrence at entry; after 24 months of treatment 9 patients (60%) achieved complete (n = 3) or near complete (n = 6) mucosal healing, and 5 of the 9 patients (56%) achieved clinical remission. The authors suggest that ADA therapy may be useful for preventing recurrence, and improving endoscopic recurrence after ileocecal resection for CD. Although this is an uncontrolled study, it is the first report to prospectively evaluate the efficacy of ADA for post-operative CD. I have similar experiences in clinical practice (not published). ADA therapy is useful for maintaining remission post-operatively in patients who were intolerant or unresponsive to IFX and AZA.

The efficacy of another biological agent, IFX for post-operative CD was evaluated in a number of prospective studies.25 Two randomized controlled trials (RCTs) confirmed that IFX therapy initiated soon after surgery was useful in preventing post-operative recurrence in CD.2,3 However, I do believe that IFX treatment should be used for selected patients at high risk of post-operative recurrence. All patients after surgery for CD do not have to receive IFX because of potential for serious adverse events and high treatment costs. In our institution, we started IFX treatment in patients who developed early endoscopic recurrence at 6 months after surgery for CD.4 We found that IFX was useful in preventing clinical recurrence and improving endoscopic recurrence. Similar results were reported by other authors.5

To evaluate the effectiveness of biologics for the prevention and treatment of post-operative recurrence in CD, further large RCTs are necessary. The following issues should be clarified in the management of post-operative CD:

  1. Should biological therapy be started soon after surgery or after confirming endoscopic or clinical recurrence?

  2. Which biological agent should be used as a first- and second-line therapy, ADA or IFX?

  3. How long should biological therapy be continued once it is started?

  4. Whether or not concomitant immunosuppressants enhance the efficacy of biologics?

Conflict of interest

None declared.


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