Anti-Tumor Necrosis Factor Antibodies for Prevention of Crohn's Disease Recurrence After Surgery: More Than a Hope

We have read with interest the article by Sartor1 illustrating the different options to improve our current management of postoperative recurrence of Crohn’s disease (CD). Sartor1 reported that to date only anti–tumor necrosis factor (TNF) antibodies, 6-mercaptopurine/ azathioprine, and 3-month administration of metronidazole or ornidazole have shown promising effects.2 In particular, Sartor1 underlined that data on anti-TNF antibody efficacy is based only on a small pilot study reporting extremely impressive results of infliximab,3 with a large multicenter international study to be reported soon. However, we believe that not all the data available in the literature have been quoted and information on antiTNF antibody effectiveness has been largely underestimated. Indeed, in 2014 Regueiro et al4 published the continuation of their previous randomized, 2-armed trial (infliximab vs placebo) and they found in an open-label study that patients on long-term infliximab therapy, irrespective of original assignment to infliximab or placebo, presented with a higher rate of endoscopic remission and a lower rate of surgical recurrence compared with other patients during a 5-year follow-up period. In 2013, after our first experience reported in a case series,5 we provided evidence of a similar great result achievable with adalimumab, administered within 4 weeks after resective surgery for CD. In our randomized, 3-armed, 2-year, follow-up study we observed that only 1 patient (6.3%) of the 16 patients in the Adalimumab treatment group had endoscopic recurrence, compared with 11 of 17 patients (64.7%) in the azathioprine group and 15 of 18 patients (83.3%) in the mesalamine group.6 Moreover, similar results were obtained in terms of clinical and radiologic recurrence at 1 and 2 years. Thus, we provide additional strong data confirming that starting anti-TNFa immediately after surgery or shortly after endoscopic recurrence provides a low recurrence rate in the long term. These data corroborate the findings already published in retrospective or open-label studies and emphasize that starting anti-TNFa drugs immediately or shortly after surgery, in particular in patients with risk factors for disease recurrence and additional surgery, represents a valid and effective approach for preventing postsurgical CD recurrence, although further data and cost-related analysis are needed.