Anti-TNF vs early resection after steroid and azathioprine failure

What is known

• LIR!C-based long-term data: early ICR patients required no repeat surgery and mostly no medical therapy, versus 48% of the anti-TNF arm requiring surgery. ¹
• A population-based cohort found early ileocecal resection associated with improved long-term outcomes compared with anti-TNF therapy. ¹
• A Markov analysis modeled azathioprine-first with resection on failure versus upfront resection in steroid-dependent terminal ileal disease. ²
• Preoperative anti-TNF failure predicts failure of a second anti-TNF attempt, though post-resection neo-terminal ileum lesions may respond anew. ³

What is unknown / caveats

• A Markov analysis favored a trial of azathioprine before resection ², whereas a population-based cohort favored early resection over anti-TNF ¹
• No retrieved trial directly compares anti-TNF vs early resection specifically after azathioprine failure
• LIR!C enrolled limited, non-stricturing ileocecal disease. Generalizes poorly to stricturing/penetrating phenotypes
• Surgical risk is elevated with active sepsis and in older patients with cardiopulmonary comorbidity ⁴
• Whether early resection outperforms anti-TNF specifically in patients who have already failed a thiopurine is not directly established by the retrieved evidence.

References

1. Agrawal M, Ebert AC, Poulsen G, Ungaro RC, Faye AS, Jess T, Colombel JF, Allin KH. Early Ileocecal Resection for Crohn's Disease Is Associated With Improved Long-term Outcomes Compared With Anti-Tumor Necrosis Factor Therapy: A Population-Based Cohort Study. Gastroenterology. 2023;165(4):976-985.e3. PMID: 37321356.

2. Kennedy ED, Urbach DR, Krahn MD, Steinhart AH, Cohen Z, McLeod RS. Azathioprine or ileocolic resection for steroid-dependent terminal ileal Crohn's disease? A Markov analysis. Dis Colon Rectum. 2004;47(12):2120-30. PMID: 15657664.

3. Ten Bokkel Huinink S, Beelen EMJ, Ten Bokkel Huinink T, Hoentjen F, G L Bodelier A, Dijkstra G, Romberg-Camps M, de Boer NK, Stassen LPS, van der Meulen AE, West R, van Ruler O, van der Woude CJ, de Vries AC, Dutch Initiative on Crohn and Colitis (ICC). Retreatment with anti-tumor necrosis factor therapy in combination with an immunomodulator for recurrence of Crohn's disease after ileocecal resection results in prolonged continuation as compared to anti-tumor necrosis factor monotherapy. Eur J Gastroenterol Hepatol. 2023;35(1):45-51. PMID: 36468568.

4. Norris B, Solomon MJ, Eyers AA, West RH, Glenn DC, Morgan BP. Abdominal surgery in the older Crohn's population. Aust N Z J Surg. 1999;69(3):199-204. PMID: 10075359.

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Draft, generated by the IBDology RAG and not yet clinician-reviewed. Answers are grounded in the retrieved literature listed above; a high faithfulness score means the answer matches its sources, not that the sources are correct.