Differentiating the postoperative management of patients with Crohn's disease according to their risk of recurrence seems to be a promising strategy, reports a study in The Lancet.

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Most patients with Crohn's disease will require surgery at some point, and disease recurrence is common. However, how best to manage patients and reduce the risk of recurrence is not entirely clear—the risks and costs of drug therapy must be weighed against the benefits. “Two main approaches have been taken to the use of medication to prevent recurrence of Crohn's disease,” explains Peter De Cruz, lead author of the Post-Operative Crohn's Endoscopic Recurrence (POCER) multicentre randomized, controlled trial. “Some patients have been put on preventive medication immediately after surgery, whereas other patients have undergone monitoring with colonoscopy with medication started only if there are signs at colonoscopy that the Crohn's disease is starting to recur.” De Cruz and colleagues investigated the best management strategy.

174 patients undergoing intestinal resection were included in the POCER study; all patients received metronidazole therapy for 3 months. Patients at high risk of recurrence also received a thiopurine or adalimumab. In addition, patients were randomly allocated to colonoscopy (active care) or not (standard care) at 6 months; drug therapy was stepped up in patients with disease recurrence at colonoscopy.

The findings demonstrate that treating according to risk of recurrence and adjusting drug therapy on the basis of colonoscopy results leads to effective disease control in the majority of patients. Notably, at 18 months, endoscopic recurrence occurred in 60 (49%) patients in the active care group compared with 35 (67%) patients in the standard care group (P = 0.03).

“Previous studies have focused on drug versus placebo—there have been no studies that have focused on strategy,” says co-author Michael Kamm. “The POCER study has defined and validated a strategy for postoperative risk assessment and management, and provides an evidence-based framework for surgeons and physicians to guide the optimal management of Crohn's disease after intestinal resection.”