Postoperative prophylaxis in smokers with penetrating CD

What is known

• The only direct prospective comparison randomized post-resection CD patients to infliximab vs azathioprine; endoscopic recurrence was 9% vs 40% and high histological activity 18% vs 80% at one year. ¹
• Active smoking, penetrating behavior, and previous surgery each significantly increase postoperative recurrence risk, defining the high-risk group in whom prophylaxis is indicated. ¹
• In the larger PREVENT RCT, infliximab reduced endoscopic but not clinical recurrence after ileocolonic resection. ^2–4
• Thiopurines outperform mesalamine for preventing recurrence in patients with two or more risk factors. ³

What is unknown / caveats

• Head-to-head data rests on a single small open-label study (n=22)
• No retrieved evidence isolates outcomes specifically in the smoking + penetrating + prior-surgery triad
• The anti-TNF advantage is consistently on endoscopic/histologic endpoints, not clinical relapse, and derives from a small underpowered comparison.

References

1. [No authors listed]. Prevention of postoperative recurrence with azathioprine or infliximab in patients with Crohn's disease: an open-label pilot study. J Crohns Colitis. 2013;7(12):e623-9. PMID: 23810678.

2. [No authors listed]. Perioperative management of ileocecal Crohn's disease in the current era. Expert Rev Gastroenterol Hepatol. 2020;14(9):843-855. PMID: 32729736.

3. Huang ZC, Yang QF, Tang J, Li M, Chao K, Gao X. Thiopurines are superior to mesalamine for preventing postoperative recurrence in patients with Crohn's disease and two or more risk factors. J Dig Dis. 2021;22(10):590-596. PMID: 34453408.

4. Ferrante M, Pouillon L, Mañosa M, Savarino E, Allez M, Kapizioni C, Arebi N, Carvello M, Myrelid P, De Vries AC, 8th Scientific Workshop of the European Crohns and Colitis O, Rivière P, Panis Y, Domènech E. Results of the Eighth Scientific Workshop of ECCO: Prevention and Treatment of Postoperative Recurrence in Patients With Crohn's Disease Undergoing an Ileocolonic Resection With Ileocolonic Anastomosis. J Crohns Colitis. 2023;17(11):1707-1722. PMID: 37070324.

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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.