Rutgeerts i3 at 6 months: anti-TNF or azathioprine

What is known

• Postoperative algorithms use a Rutgeerts score of ≥ i2, the conventional threshold for endoscopic recurrence, as the trigger to step up to an anti-TNF. ²
• The PREVENT trial (n=297) found infliximab lowered endoscopic recurrence versus placebo at week 76 (30.6% vs 60.0%), while the difference in the primary clinical-recurrence endpoint was not significant (12.9% vs 20.0%). ³
• A meta-analysis of 10 RCTs reported anti-TNF gave the greatest reduction in clinical and endoscopic recurrence; thiopurines have only modest efficacy and poorer tolerability. ^1,2

What is unknown / caveats

• No retrieved study directly compares azathioprine vs anti-TNF in i3 postoperative disease
• Many postoperative patients have prior anti-TNF exposure, which the retrieved sources note complicates agent selection
• PREVENT showed endoscopic but not clinical recurrence benefit for infliximab
• The evidence supports anti-TNF over thiopurine by algorithm and indirect comparison, not by a direct trial in i3 disease.

References

1. Strong SA. Surgical treatment of inflammatory bowel disease. Curr Opin Gastroenterol. 2002;18(4):441-6. PMID: 17033319.

2. Vuitton L, Koch S, Peyrin-Biroulet L. Preventing postoperative recurrence in Crohn's disease: what does the future hold?. Drugs. 2013;73(16):1749-59. PMID: 24132799.

3. Regueiro M, Feagan BG, Zou B, Johanns J, Blank MA, Chevrier M, Plevy S, Popp J, Cornillie FJ, Lukas M, Danese S, Gionchetti P, Hanauer SB, Reinisch W, Sandborn WJ, Sorrentino D, Rutgeerts P; PREVENT Study Group. Infliximab Reduces Endoscopic, but Not Clinical, Recurrence of Crohn's Disease After Ileocolonic Resection. Gastroenterology. 2016. PMID: 26946343.

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Draft, generated by the IBDology RAG and not yet clinician-reviewed. Answers are grounded in the retrieved literature listed above; a high faithfulness score means the answer matches its sources, not that the sources are correct.