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AGA guideline highlights importance of medical prophylaxis, monitoring for Crohn's recurrence after surgery
The AGA has released new guideline recommendations for the management of Crohn’s disease after surgical resection, which emphasize the importance of monitoring patients for recurrence after surgery, and medical prophylaxis to prevent recurrence in high-risk patients.
“One of the key take-home messages from these guidelines is that patients who undergo surgery for Crohn’s disease need follow-up with their gastroenterologists afterward because recurrence of disease is so common,” Geoffrey C. Nguyen, MD, of the Mount Sinai Hospital Center for Inflammatory Bowel Disease, University of Toronto, Canada, told Healio Gastroenterology. “Even though they may be feeling completely well after surgery, patients need to be monitored closely (within 6-12 months) for early recurrence, usually with colonoscopy. It’s also important for gastroenterologists to assess whether a patient is at high-risk for Crohn’s recurrence since these patients may benefit from starting medical therapy that can prevent relapse.”
Geoffrey C. Nguyen
To outline strategies for reducing disease recurrence in Crohn’s patients who have achieved remission after bowel resection, Nguyen and colleagues reviewed relevant literature and made six main recommendations, the strength of which were evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework.
They recommended that these patients ...
- should receive early pharmacological prophylaxis rather than endoscopy-guided pharmacological treatment, although certain low-risk patients “may reasonably” choose the latter;
- should receive anti-TNF and/or thiopurines rather than other agents, but again, certain low-risk patients “may reasonably” opt to receive nitroimidazole antibiotics for 3-12 months;
- should not receive mesalamine or other 5-aminosalicylates, budesonide or probiotics due to insufficient evidence;
- should undergo postoperative endoscopic monitoring at 6-12 months vs. no monitoring whether receiving pharmacological prophylaxis or not; and
- should begin or optimize anti-TNF and/or thiopurine therapy rather than continue monitoring alone if they experience asymptomatic endoscopic recurrence, although certain patients “may reasonably choose continued endoscopic monitoring.”
“Although all patients should undergo ileocolonoscopy at 6 to 12 months after surgical resection, surveillance for endoscopic recurrence is most important for patients not on any pharmacological prophylaxis,” Nguyen and colleagues noted.
They also added that a validated score for predicting endoscopic and clinical recurrence based on clinical features “would enable more effective implementation of these guidelines.”
Further research is needed to determine the optimal frequency of endoscopic monitoring after surgical resection, to compare medical therapies after the onset of asymptomatic endoscopic recurrence, and to evaluate the role of newer classes of biologics for preventing postoperative recurrence, they concluded. – by Adam Leitenberger
Disclosures: Nguyen reports no relevant financial disclosures. Please see the guideline for a full list of all other authors’ relevant financial disclosures.