Letter: Biological therapies are effective for prevention of post-operative Crohn's disease recurrence

SIRS, We have read with interest the systematic review by Jones et al. 1 regarding use of prophylactic drugs to prevent Crohn’s disease (CD) recurrence after resective surgery. This study tried to summarise the available knowledge on the effi cacy and safety of thiopurines and anti-TNF compounds in the post-operative setting, with the aim to modify the natura l history of CD. The authors analysed four randomised controlled trials including 433 patients on thiopurine therapy and one involving 24 patients on anti-TNF therapy, concluding that evidence for routine use of thiopurine treatment in post-operative CD is heterogeneous and unconvincing and that evidence for prophylactic anti-TNF use is limited, though promising, being its routine use guided by early assessment of relapse patients. We apprecia ted the efforts m ade by the authors to clarify this important area of debate. However, given the authors conducted a systematic review, we are surprised that not a ll ava ilable published data in the literature were quoted. Indeed, following our case series published in 2012, which reported 100% clinical, radiological and endoscopic remission in six anti-TNF-naıve adalimumab (ADA)-treated patients 3 years after surgery for ileal/ileocolonic stricturing, 2 we have more recently published the first, randomised, three-armed , mes alazine-controlled study evaluating the rate of endoscopic and clinical recurrence with 2 years of follow-up in CD operated patients treated with ADA, azathioprine or mesalazine.3 In this study, the rate of endoscopic recurrence was significantly lower in the ADA group compared with azathioprine or mesalazine (6.3% vs. 64.7% and 83.3%, respectively). Moreover, there was a significantly lower proportion of patients with clinical recurrence in the ADA group compared with azathioprine or mesalazine (12.5% vs. 64.7% and 50%, respectively). Finally, we provided detailed clinical, radiological and endoscopic data at 1 and 2 years after surgery in patients treated with azathioprine, and we confirmed the limited efficacy of this drug administered as prophylactic treatment in preventing endoscopic and clinical CD recurrence .4 In conclusion our data, together with those published by Regueiro et al.,5 provide strong evidence that anti-TNF drugs are much more effective than the traditional medications in preventing endoscopic and clin- ical post-operative recurrence of CD and provides a rationale for aggressive post-operative chemoprevention with biological therapy. Further and larger controlled trials are needed to establish the actual impact of this kind of drug on the rate of disease recurrence and the economic impact of this modern approach.