Can We Change the Natural History of Crohn's Disease with Early Immunomodulation?

Abstract

In both children and adults, the natural history of Crohn's disease (CD) is characterized by relapsing and remitting bouts of intestinal inflammation, often associated with a progressive shift from inflammatory to complicated stricturing or penetrating disease behavior. The past 2 decades have seen a dramatic shift in therapeutic approach with the increasingly common use of early thiopurine immunomodulation. These maintenance medications were initially introduced primarily as corticosteroid-sparing agents capable of minimizing recurrent flares of inflammatory disease and have proven to be quite efficacious. Increasing evidence suggests, however, that thiopurines may only delay rather than prevent the development of complicated disease behavior. Data from both adult and pediatric CD populations from around the world are reviewed in terms of the effect of early immunomodulation on progression to complicated disease behavior, need for surgery, and prevention of recurrent disease after resection. The effect of thiopurines on the growth of children is also reviewed.

Azithromycin and metronidazole versus metronidazole-based therapy for the induction of remission in mild to moderate paediatric Crohn’s disease : a randomised controlled trial

“…However, our study differed by the fact that it was performed in children with very short disease duration, a cohort that might be more responsive to medical therapy, especially antibiotics 44. An additional difference, typical of a paediatric cohort of patients with CD, is that the majority of children had colonic involvement which might respond better to antibiotic therapy 20.…”

Perioperative optimization of Crohn's disease

“…Steroids and probiotics do not assist in the prevention of postoperative recurrence, 169 but azathioprine can delay endoscopic postoperative recurrence. 169 , 170 Biologics presented the most promising data in terms of reducing postoperative recurrence, but this potential must be verified through large randomized control trials. 171 , 172 , 173 , 174 , 175 …”

Immunomodulators: Friends or Enemies in Surgery for Crohn’s Disease?

“…A key question when it comes to immunomodulators is whether they are able to slow down disease progression in CD and thereby reduce the need of hospitalizations and the risk of surgery [89][90][91] .…”