Is the anti-TNF agent infliximab effective in treatment of patients with stricturing-type Crohn's disease? What is the best approach to these patients?
||Bret A. Lashner, MD
Professor of Medicine, Cleveland Clinic, Cleveland, Ohio
Infliximab plus the other antitumor necrosis factor (anti-TNF) agents, adalimumab and certolizumab, are effective in patients with Crohn's disease who have inflammatory-type disease. By the time intestinal strictures have developed, anti-TNF agents are no longer effective. Some evidence indicates that early Crohn's disease begins as inflammatory-type disease, and over time stricturing complications develop.
Evidence has also suggested that prescribing anti-TNF agents early in the course of disease is associated with a better response and a lower risk of developing complicated disease than starting anti-TNF treatment after strictures have developed. That said, some strictures have an inflammatory component and may respond to anti-TNF agents. These patients with strictures should be evaluated with computed tomographic (CT) enterography, small bowel follow-through, or ileocolonoscopy to document inflammatory-type lesions prior to instituting anti-TNF agents.
Therefore, in a patient with Crohn's disease with an intestinal stricture, prior to starting therapy with an anti-TNF agent, such as infliximab, I would suggest that the patient be monitored and only receive an anti-TNF agent if inflammatory-type disease is documented. Patients with stricturing disease who do not have an inflammatory component to their stricture should have surgical therapy.