Prophylactic medication for the prevention of endoscopic recurrence in Crohn's disease: a prospective study based on clinical risk stratification

BACKGROUND: To prevent recurrence after ileocolonic resection (ICR) in Crohn's disease (CD), postoperative prophylaxis based on risk stratification is recommended in international guidelines. This study aimed to evaluate postoperative CD recurrence after implementation of a clinical management algorithm and determine the predictive value of clinical and histological risk factors (RF). METHODS: In this multicenter, prospective cohort study, CD patients (≥16 years) scheduled for ICR were included. The algorithm advised no postoperative medication for low-risk patients, and treatment with prophylaxis (immunosuppressant/biological) for high-risk patients (≥1 RF: active smoking, penetrating disease, prior ICR). Clinical and histologic RF (active inflammation, granulomas, plexitis in resection margins) for endoscopic recurrence (Rutgeerts' score ≥i2b at 6 months) were assessed using logistic regression and ROC curves based on predicted probabilities. RESULTS: 213 CD patients after ICR were included (age 34.5 years; 65% women) (93[44%] low-risk; 120[56%] high-risk [45[38%] smoking; 51[43%] penetrating disease; 51[43%] prior ICR]). Adherence to the algorithm was 82% in low-risk (no prophylaxis) and 51% in high-risk patients (prophylaxis). Endoscopic recurrence was higher in patients treated without prophylaxis than with prophylaxis in both low (45% vs 16%, p=.012) and high-risk (49% vs 26%, p=.019). Clinical risk stratification including the prescription of prophylaxis corresponded with an area under the curve (AUC) of 0.70 (95%CI 0.61-0.79). Clinical RF combined with histological RF increased the AUC to 0.73 (95%CI 0.64-0.81). CONCLUSION: Adherence to this management algorithm is 65%. Prophylactic medication after ICR prevents endoscopic recurrence in low and high-risk patients. Clinical risk stratification has an acceptable predictive value, but further refinement is needed