Management of Crohnʼs disease of the ileal pouch with adalimumab

Abstract

Crohn's disease (CD) of the pouch can develop in patients with ileal pouchanal anastomosis (IPAA) and result in severe morbidity and significant chance of reservoir loss. This study provides both short-term and long-term efficacy of adalimumab in treating these patients. From our prospectively maintained Pouchitis Database, we identified 48 patients who received adalimumab for CD of the pouch from June 2006 to June 2011. Inclusion criteria were CD of the pouch who failed mediacal therapy and otherwise qualified for permanent pouch diversion or excision. All qualified patients received the standard dosing regimen of subcutaneous injection adalimumab (160 mg at week 0, 80 mg at week 1, and 40 mg every other week thereafter). Complete clinical response was defined as resolution of symptoms. Partical clinical response was defined as improvement in symptoms. Endoscopy inflammation before and after therapy was recorded, using the Pouchitis Disease Activity Index (PDAI) endoscopy subscores. Mocosal healing was defined as a subtotal of endoscopic mucosal inflammation scores no more than 1. The median duration of adalimumab therapy was 41 (interquartile range [IQR] 30-64) weeks. At a short term follow-up of median 8 weeks (interquartile range [IQR] 5.0-10.0), 24/48 (50%) patients had a complete response, 10/48 (21%) had a partial response, and 14/48 (29%) had no response. After a median follow-up of 25.1 (IQR 5.3-44.2) months, 16/48 (33%) patients still had a complete response, 10/48 (21%) had a partial response, and 22/48 (46%) had no response. At the end of the follow-up, thirteen (50%) patients among 26 who remained in response achieved mucosal healing of the pouch. In total, nine patients (19%) eventually either had their pouch resected or had a permanent diverting ileostomy. Adalimumab was effective long-term in IPAA patients complicated with CD of the pouch.