P428 Rescue therapy with anti-TNF therapy in patients with Crohn's Disease and post-operative recurrence with intolerance or failure of thiopurines
B. Oller*1, M. Mañosa1, Y. Zabana1, M. Piñol2, J. Troya2, J. Boix1, V. Moreno1, E. Cabré1, 3, E. Domenech1, 3
1Hospital Universitari Germans Trias I Pujol, Gastroenterology, Badalona, Spain, 2Hospital Universitari Germans Trias I Pujol, General Surgery, Badalona, Spain, 3CIBEREHD, Gastroenterology, Barcelona, Spain
The postoperative recurrence (POR) in Crohn's disease (CD) occurs in >75% within the first year after intestinal resection if no preventive treatment is started. Despite an early use of thiopurines, a 40% of patients presents POR one year after surgery. It is not well established what should be done in front of recurrent lesions because there are a few controlled studies about this setting. Aims: To describe the evolution of POR in pacients who receive anti-TNF agents as a treatment for POR.
We identified all the patients affected of CD with intestinal resection and ileocolic anastomosis who started anti-TNF therapies because of POR and not indicated as primary prevention. We defined endoscopic recurrence (ER) using Rutgeerts endoscopic score and we classified the recurrence as moderate (i2 Rutgeerts) or severe (i3 and i4 Rutgeerts) and Clinical recurrence (CR) as the development of symptoms that required changes in the treatment for CD. We followed the clinical and endoscopic evolution.
32 patients were included of whom 53% men; 53% ileum disease; 47% ileocolic disease; 43% stenosing patern and 40% penetrating pattern. We toke into account the three risk factors for POR which are: active smoking after surgery (60%), penetranting disease pattern and previous surgery (25%). 85% of patients have one or more risk factors. Before the main resection 62% of patients had been treated with thiopurines and 31% with anti-TNF agents. 72% started prevention with thiopurines after the main surgery and 16% with 5-ASA. Anti-TNF therapies had been started for moderate ER in 31% of patients and for severe ER in 69%. 87% of patients started infliximab and 13% adalimumab, and 74% maintained the initial anti-TNF. 88% used inmunosupressant treatment associated to anti-TNF agents, most of them the same which had been used previously. After a median follow up of 17 months since biological treatment had been started, we had imaging test in 29 out of 32 patients (80% with colonoscopy). 69% of cases had an improvement in the Rutgeert's score. Besides, a 60% had clinical improvement too. At the end of the follow up, 25% needed another intestinal resection, all of them had CR.
Anti-TNF therapies are a valid and alternative treatment for POR in patients in whom thiopurines had failed or had not been well tolerated. In spite of that, in at least a 25% of cases they will not be enough to avoid a new intestinal resection in a short-medium term. These data suggest that primary prevention with thiopurines associated to an early endoscopic monitoring could be a cost-effective strategy to prevent POR.