Stemming the tide with ileocaecal Crohn's disease: when is pharmacotherapy enough?

According to the long-term follow-up data of the LIR!C study, 38% of infliximab-treated patients were still treated with infliximab at the end of their follow-up period, while 14% had switched to another biologic or had received immunomodulator or corticosteroid treatment and 48% had CD-related surgery. Only the combination with an immunomodulator was associated with a greater likelihood of continuing anti-TNF therapy. Patients with ileocecal CD for whom pharmacotherapy might be sufficient are probably those with no risk factors for CD-related surgery. From a clinical/demographic aspect, patients with a Montreal B1 phenotype and with low disease activity are more likely to respond to drug therapy. Radiologic criteria identified as associated with a need for surgery are large thickness of the intestinal wall, loss of mural stratification, increased fibrofatty proliferation, mesenteric edema, and the presence of different enhancement patterns. Furthermore, pharmacotherapy is more likely to be sufficient in the absence of strictures, fistulas or abscesses. Based on genetic analyses, patients without NOD2, HLA-G and SLC11A1 mutation genes would have a better chance of avoiding surgery. In addition, patients with a high risk of recurrence or post-operative complications if operated (patients with active smoking, previously resected CD or American Society of Anesthesiologists score fitness grade III) may benefit more from medical treatment than from surgery.