Maintenance Therapy

Maintenance therapy is recommended for patients with SB CD, given the recurrent nature of CD. In addition to disease location and pattern, choice of medication depends on patient compliance and the method by which remission is achieved. The efficacy of 5-ASA compounds in maintaining medically induced remission has not been consistently demonstrated in controlled trials. It is presumed (not yet proven in a controlled fashion) that they are alone ineffective in maintaining remission induced by immunomodulators or infliximab. For steroid-induced remission, mesalamine (Pentasa) at 4 g/d may allow steroid withdrawal and avoid steroid dependency.

Maintenance budesonide for at least 7 months is discussed in an Editor's Note earlier. In most cases of SB CD, particularly those with extensive jejunoileitis, immunomodulatory therapy is necessary to maintain remission. Treatment with AZA or 6-MP therapy allows maintenance of remission in approximately 67% of patients or higher. Although maintenance of remission with continued use of AZA has been demonstrated to be effective when compared with placebo for a duration of up to 5 years, many patients continue to derive benefit from this therapy beyond 5 years. Thus, AZA or 6-MP maintenance should probably be continued indefinitely unless therapy fails or patients have significant concerns regarding long term therapy.

MTX is another immunomodulatory agent that has been shown to be effective for maintaining medically induced remission (Feagan et al, 2000). The dose of MTX for maintenance therapy (15 mg/week intramuscularly) is lower than that for induction therapy. Approximately 65% of patients remain in remission at 40 weeks on such a therapy. Returning the dosage to 25 mg 1 month weekly for a number of weeks has restored remission in some patients.

Infliximab

In patients who respond to an initial infliximab infusion, repeated therapy every 8 weeks allows maintenance of remission in 28 to 38% of patients at 1 year (Hanauer et al, 2002). Although concurrent immunosuppressive therapy minimizes the formation of antibodies against infliximab, thereby possibly decreasing the risk of infusion reactions and prolonging the duration of response, this combination therapy theoretically may result in a greater risk of infectious complications. The optimal strategy is currently unknown (Sandborn, 2003). Owing to the issue of immunogenecity, however, maintenance therapy with infliximab administered on a regular basis instead of on demand is recommended, even if concurrent immuno-suppressive therapy is employed.

In general, for patients with SB CD that require an immunosuppressant or infliximab to induce remission, therapy is continued for maintenance purpose once remission is achieved. In patients with steroid-induced remission, maintenance therapy with immunomodulatory agents or infliximab should be considered if they have had recurrent flares or if the SB disease is extensive. Traditional corticosteroids should not be used as long term therapy. Maintenance therapy with oral budesonide at 6 mg/d may increase the duration of remission, but this benefit appears to be only for short term and has not been consistently demonstrated in clinical trials. Because prolonged use of budesonide can also result in untoward toxicities as with traditional corticosteroids, budesonide maintenance therapy should be reserved for patients in whom remission cannot be maintained with other agents and surgery is not an option.*

Postresection

In patients with surgically induced remission, mesalamine is beneficial in some patients in preventing postoperative recurrence in patients with SB CD. 6-MP at 50 mg/d may also be effective and may be superior to mesalamine (Achkar and Hanauer, 2000). Use of higher doses of 6-MP or AZA is probably appropriate but has not been adequately evaluated. Although no controlled studies have been reported for MTX and infliximab as postsurgical maintenance therapy, these agents might be considered in individuals with recurrent SB disease requiring surgery and with risk factors for early postoperative recurrence (eg, penetrating indication for initial surgery, and longer pre-operative disease duration), who have failed or are intolerant of mesalamine or AZA/6-MP maintenance therapy.

Constipation Prescription

Constipation Prescription

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