Short Disease Duration Does Not Always Indicate Early Crohn’s Disease

We read with interest the article recently published by Faleck et al,1Faleck D.M. et al.Clin Gastroenterol Hepatol. 2019; https://doi.org/10.1016/j.cgh.2018.12.040Abstract Full Text Full Text PDF Scopus (32) Google Scholar in which they reported the results of a subanalysis performed within the US Vedolizumab for Health Outcomes in Inflammatory Bowel Diseases (VICTORY) Consortium. The investigators observed that the early use of vedolizumab (<2 years since the diagnosis) in patients with Crohn's disease was associated with higher rates of clinical remission, steroid-free clinical remission, and mucosal healing. Although we believe that these results provide relevant information for our clinical practice, it is necessary to highlight some aspects when interpreting the data, especially when evaluating the possible relationship between the time since the diagnosis of Crohn’s disease and its severity. The group of patients with a shorter disease duration was composed of 62 patients in whom 39% showed a stenosing or penetrating behavior, 23% had fistulas, and 35% had already undergone surgery. In addition, 60% of the cases already had shown an inadequate response to anti–tumor necrosis factor biologics, with up to 34% of subjects who had been exposed to at least 2 of these drugs. These results are in line with findings from European centers, in which up to 39% of patients showed advanced intestinal lesions shortly after diagnosis.2Fiorino G. et al.J Crohns Colitis. 2017; 11: 274-280Crossref PubMed Google Scholar The relevance of these data comes from the association of bowel damage with a higher rate of hospitalization and surgery during follow-up evaluation. Regarding the treatment strategy in Crohn’s disease, we strongly believe that early therapy undoubtedly will benefit an important number of patients by preventing the progression of the inflammatory process toward more aggressive and complicated forms of the disease. For this reason, we consider it of great importance to extend our research on these early stages of the disease because, despite a short period of time since the diagnosis, it is possible that this group of patients represents an early and severe disease phenotype. Moreover, some factors, such as the time since the onset of the first symptoms or even a possible delay in the establishment of a definite diagnosis, may influence our findings.3Schoepfer A. et al.J Crohns Colitis. 2015; 9: 597-598Crossref PubMed Scopus (4) Google Scholar The inclusion of patients who already have developed complications (stenosis or fistulas) or who previously had undergone surgery limits our capacity to draw conclusions about the disease-modifying effect of current therapeutic options on the natural history of Crohn’s disease. Despite being considered early, the characteristics of the cohort of patients analyzed by Faleck et al1Faleck D.M. et al.Clin Gastroenterol Hepatol. 2019; https://doi.org/10.1016/j.cgh.2018.12.040Abstract Full Text Full Text PDF Scopus (32) Google Scholar included a significant proportion of subjects (at least 60%) who will not fulfill the early Crohn’s disease criteria as defined by the Paris definition.4Peyrin-Biroulet L. et al.Am J Gastroenterol. 2012; 107: 1770-1776Crossref PubMed Scopus (82) Google Scholar We have observed an increase in the number of studies (both in clinical trials and observational studies) that assessed the efficacy of multiple drugs in the early phases of Crohn’s disease, but the heterogeneity of the criteria used to define early disease limits our capacity to obtain strong conclusions in this field. Although we received the present results reported by Faleck et al1Faleck D.M. et al.Clin Gastroenterol Hepatol. 2019; https://doi.org/10.1016/j.cgh.2018.12.040Abstract Full Text Full Text PDF Scopus (32) Google Scholar with great interest, we believe that future studies should take these aspects into account to obtain robust data on early disease control, prevention of intestinal damage, and how to control the progression of the disease from its early stages. Shorter Disease Duration Is Associated With Higher Rates of Response to Vedolizumab in Patients With Crohn’s Disease But Not Ulcerative ColitisClinical Gastroenterology and HepatologyVol. 17Issue 12PreviewPatients with Crohn’s disease (CD), but not ulcerative colitis (UC), of shorter duration have higher rates of response to tumor necrosis factor (TNF) antagonists than patients with longer disease duration. Little is known about the association between disease duration and response to other biologic agents. We aimed to evaluate response of patients with CD or UC to vedolizumab, stratified by disease duration. Full-Text PDF Open AccessReplyClinical Gastroenterology and HepatologyVol. 17Issue 8PreviewWe thank Drs Rodriguez-Lago and Acosta for their interest in our study and appreciate their comments regarding early Crohn’s disease (CD). We agree that there is a definite need for better definitions and criteria for early CD because the current definition is based on expert consensus. We chose the 2-year cutoff for defining early CD because most post hoc analyses of tumor necrosis factor antagonist clinical trials have used this definition when examining differences in response rates by disease duration. Full-Text PDF