The Tortoise (Endoscopy-Driven Treatment) and the Hare (Prophylactic Treatment): Who Wins the Race to Beat Post-Operative Recurrence of Crohn’s Disease?

Management of Post-Operative Crohn’s Disease: Knowns and Unknowns

“…The risk of overtreatment lies in exposing patients to undesired adverse events, along with the long-term risks and costs of associated medications. On the other hand, undertreatment may lead to missed opportunities to prevent bowel damage and complications, and to the necessity of additional surgery [144]. To balance the aggressive strategy of immediate systematic medical prophylaxis with the more conservative strategy of endoscopy-guided therapy, previous research has shown that a subset of patients has specific risk factors that place them at increased risk of early disease recurrence [144].…”

“…Despite the low quality of the evidence, most international guidelines recommend this "risk stratification strategy" (weak recommendation), in which early medical prophylaxis is started in only high-risk patients. However, the definition of a high-risk patient is not homogeneous between guidelines (at least one risk factor vs. >one risk factors) and the current approach to risk stratification in recurrence demonstrated limited effectiveness in recent real-world studies, potentially resulting in many individuals receiving biologic therapy with uncertain concrete benefit [12][13][14]144]. Indeed, despite the retrospective design of most studies published after these guidelines, the majority of them confirmed the need for multiple risk factors in order to achieve benefit from prophylaxis therapy [11].…”

“…In the near future, when the weight of all the risk factors will be clearer (also the histological ones), the concept of a cumulative effect due the presence of multiple risk factors and the right number of risk factors needed to define a high-risk patient will help the physician in determining the most accurate threshold for initiating prophylactic therapy with an optimal risk-benefit ratio [11,85,144]. Furthermore, an additional tool in the management of post-operative CD may come from the evidence on the potential role of biomarkers, in particular fecal calprotectin, as early predictors of disease recurrence [146,147].…”