Int J Colorectal Dis DOI 10.1007/s00384-014-1984-x
LETTER TO THE EDITOR
Long-term prevention of postoperative Crohn’s disease recurrence with azathioprine: the wolf in the sheep clothing Paul M. Robb & Dario Sorrentino
Accepted: 4 August 2014 # Springer-Verlag Berlin Heidelberg 2014
Dear Editor: Postoperative recurrence (POR) of Crohn’s disease (CD) is a frequent sequela of surgery, and might be associated with many risk factors of which smoking, previous surgery, penetrating disease, and concomitant perianal disease are most frequently recognized as significant [1–3]. Risk stratification is crucial when choosing postsurgical strategies for prevention of POR. Many authors recommend treating high-risk patients (>1 risk factors) with anti-TNF agents immediately after surgery [1–3]. For patients at low/intermediate risk of relapse (≤1 risk factor), it is less clear how to prevent POR. Many initiate azathioprine with or without metronidazole immediately after surgery [4], the rationale being that for such patients a less effective medication could be sufficient. Most authors also recommend to follow-up these patients with colonoscopy and continue therapy if no lesions are found over time. However, there might be risks associated with this strategy as illustrated here. A 62-year-old male affected by stricturing CD underwent right hemicolectomy with 10 cm terminal ileum resection in 2003. It was his first surgery for CD. He never smoked; he never had perianal disease; and he had no other risk factors for disease recurrence. During surgery, a fistula tract—indicating penetrating disease—was visualized and removed. After surgery, he was immediately started on azathioprine 2.5 mg/kg body weight which he tolerated well over the years. He underwent surveillance colonoscopy every 2 years with all the procedures being negative for POR. All along, complete P. M. Robb : D. Sorrentino (*) IBD Center, Division of Gastroenterology, Virginia Tech-Carilion School of Medicine, 3 Riverside Circle, Roanoke, VA 24016, USA e-mail: [email protected] D. Sorrentino Department of Clinical and Experimental Medical Sciences, University of Udine School of Medicine, Udine, Italy
blood counts, complete metabolic profiles, and C-reactive protein [CRP]—repeated at 6–12 month intervals—were within normal limits. Azathioprine was continued due to the conviction that it had led to the successful prevention of POR. The patient had no other medical issues except for mild arterial hypertension, treated with beta-blockers. In 2011, he presented to us with weight loss (10 kg in the past 12 months), malaise, night sweats, and occasional abdominal pain. His blood tests showed a reduced hemoglobin (9.0 g/dL—normal range 13.8 to 17.2 g/dL) and an elevated CRP (5.2 mg/L— normal range
LETTER TO THE EDITOR
Long-term prevention of postoperative Crohn’s disease recurrence with azathioprine: the wolf in the sheep clothing Paul M. Robb & Dario Sorrentino
Accepted: 4 August 2014 # Springer-Verlag Berlin Heidelberg 2014
Dear Editor: Postoperative recurrence (POR) of Crohn’s disease (CD) is a frequent sequela of surgery, and might be associated with many risk factors of which smoking, previous surgery, penetrating disease, and concomitant perianal disease are most frequently recognized as significant [1–3]. Risk stratification is crucial when choosing postsurgical strategies for prevention of POR. Many authors recommend treating high-risk patients (>1 risk factors) with anti-TNF agents immediately after surgery [1–3]. For patients at low/intermediate risk of relapse (≤1 risk factor), it is less clear how to prevent POR. Many initiate azathioprine with or without metronidazole immediately after surgery [4], the rationale being that for such patients a less effective medication could be sufficient. Most authors also recommend to follow-up these patients with colonoscopy and continue therapy if no lesions are found over time. However, there might be risks associated with this strategy as illustrated here. A 62-year-old male affected by stricturing CD underwent right hemicolectomy with 10 cm terminal ileum resection in 2003. It was his first surgery for CD. He never smoked; he never had perianal disease; and he had no other risk factors for disease recurrence. During surgery, a fistula tract—indicating penetrating disease—was visualized and removed. After surgery, he was immediately started on azathioprine 2.5 mg/kg body weight which he tolerated well over the years. He underwent surveillance colonoscopy every 2 years with all the procedures being negative for POR. All along, complete P. M. Robb : D. Sorrentino (*) IBD Center, Division of Gastroenterology, Virginia Tech-Carilion School of Medicine, 3 Riverside Circle, Roanoke, VA 24016, USA e-mail: [email protected] D. Sorrentino Department of Clinical and Experimental Medical Sciences, University of Udine School of Medicine, Udine, Italy
blood counts, complete metabolic profiles, and C-reactive protein [CRP]—repeated at 6–12 month intervals—were within normal limits. Azathioprine was continued due to the conviction that it had led to the successful prevention of POR. The patient had no other medical issues except for mild arterial hypertension, treated with beta-blockers. In 2011, he presented to us with weight loss (10 kg in the past 12 months), malaise, night sweats, and occasional abdominal pain. His blood tests showed a reduced hemoglobin (9.0 g/dL—normal range 13.8 to 17.2 g/dL) and an elevated CRP (5.2 mg/L— normal range
