THE CASE-AGAINST - THE CASE AGAINST ROUTINE POSTOPERATIVE THERAPY FORPREVENTION OF RECURRENCE IN CROHNS-DISEASE

Crohn's disease is inevitably characterized by episodes of relapse fol lowed by remission. The majority of patients will repair at least one resection, unfortunately ly many will have, at some time in future, fu rther recurrences requiring additional surgery. Faced with this clinic al situation, the physician or surgeon may respond to the therapeutic imperative, i.e., it is better to do something rather than to do nothi ng at all (i.e., treat the patient). Because of these factors, various authors have suggested that the aminosalicylates or; in certain cases , azathioprine, should be prescribed following resection. From a healt h system point of view, the case for maintenance therapy must be reviw ed against several criteria. First, the therapy to be prescribed must be safe for patients over the long term. For the most part, the safety profile of mesalamine has been well established There is also increas ing evidence for the safety of azathioprine when used in chronic infla mmatory diseases such as rheumatoid arthritis. Second, there must be o bjective evidence of efficacy as assessed by randomized controlled dou ble-blind trials. To date, several trials have been performed, unfortu nately the most recent have only been reported in abstract form. The r esults of the trials have been contradictory; with a mixture of positi ve and negative findings. There is a lack of consistency Sor bath the dose response and preferred disease site, the use of placebos, the eva luation of outcome and the statistical analysis. Third, the cost-benef it ratio must favour the therapy. Calculation of the number to reat (N NT) to prevent? one recurrence is often helpful. Finally: compliance i n a group of patients who often decide on surgery so that they can sto p taking medication must be considered. A variety of criteria have bee n developed to assist in making choices regarding prophylaxis. The fir st relates to the ease of treating the patient with recurrence. Some p atients will respond promptly to conventional therapy and enter remiss ion. Unfortunately, this is I?of the case for the majority of patients . We lack predictors of response. The second concerns the issue as to whether or not the condition to De prevented recurrence, is a ''seriou s'' event. There would be little discussion of that issue at an IBD me eting! The third considers the possibility of adverse events related t o the prophylaxis. Again, there does not appear-to be concern related to safety. It is the final criterion regarding effectiveness that bala nces the argument against a routine recommmendation for post-operative maintenance therapy.