Prediction of a Disease Phenotype (Clinical Course) and a Treatment Strategy for Crohn's Disease―Step-up vs Top-down Therapy Ichiro Hirata 1 1Department of Gastroenterology, Fujita Health University, School of Medicine, Toyoake, Japan Keyword: Crohn病 , 自然史 , 病型 , 予後予測因子 , top-down治療 pp.1812-1818
Published Date 2007/12/25
DOI https://doi.org/10.11477/mf.1403101236
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 The natural course of Crohn's disease (CD) is characterized by flare-ups altered with periods of remission, but the clinical course and prognosis are not the same among patients. If we might predict the prognosis and responce to a treatment in each CD patient at the point of diagnosis of CD, the choice of an appropriate therapy would be possible. On this account a varied phenotypic classification was proposed, including the Vienna classification. As a result, it was made clear that the anatomical location of lesions (ileal, ileo-colic, colonic, ano-rectal) was a more stable factor than disease behavior (inflammation, stricturing, penetrating) for classification of the CD phenotype. Futhermore, we should be able to predict the prognosis and responce to a treatment of each CD patient by evaluating additional factors other than the factors in the current classification.

 In the case of the need for intestinal resection, the progression towards structuring and/or penetrating behavior and developing steroid dependency in the disease course of CD, it may be said that the patients enter an intractable clinical course. Predictive factors related to the intractable clinical course include young-age onset, active smoking, extensive lesion, need for steroids at diagnosis, perianal disease and extraintestinal manifestation.

 When these factors are recognized at the time of CD diagnosis, early induction of the most aggressive treatment such as the Top-down (TD) therapy is necessary in order to prevent the development towards a serious status of disease. The possibility of achieving change in the natural history of CD, using aggressive treatment by TD therapy including immunomodulators (Azathioprine:AZA) and biologics (Infliximab:IFX) from the early stage of CD is considered. However, many points remain to be elucidated before definite conclusions can be reached.

 In other words, it is necessary to elucidate whether aggressive therapy should be inducted for unintractable (mild) cases despite the adverse effect of the drugs used. Also, how to add the scheduled therapy of IFX after TD therapy, whether the combination therapy with IFX and immunomodulators is always necessary. We need an accumulation of cases with long term (more than ten years) course treated with TD therapy, in order to make scientific judgments.

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