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Editor,—We read with interest the occasional viewpoint by Sahmoud and Mary (Gut1997;40:284–5). As is too often the case in such reviews, the authors have failed to identify all of the relevant literature pertinent to the topic: the maintenance of remission or prevention of recurrence of Crohn’s disease. For example, with regard to azathioprine, rather than two trials of treatment, actually six trials (including the NCCDS Parts I and II) have been published. The results were summarised recently in a meta-analysis.1 This systematic review concluded that the common odds ratio for maintaining remission for azathioprine treated patients was 2.3 (95 confidence interval (CI) 1.8 to 2.9) and that there was a relation between the cumulative dose of azathioprine prescribed and the response. Azathioprine should be considered an option for maintenance treatment.
The authors have also selectively reviewed the literature with regard to mesalazine. Turning to the postoperative population, a large North American trial2 which identified a benefit for mesalazine for prevention of recurrence has been ignored, as well as trials which used endoscopic recurrence as a surrogate end point.3 A second systematic review, published in the same year as that of Messoriet al reached similar conclusions and has been updated recently.4 Patients who received mesalazine were more likely to remain in remission compared with those on placebo. The relative risk of relapse was 0.63 (95% CI 0.50 to 0.79) for patients receiving mesalazine as compared with placebo.
We agree with the authors that additional studies are required and that differences in patient selection provides a likely explanation for differences in response. Identification of patients at higher risk of relapse could result in more cost effective treatment. Results have been conflicting with regard to clinical attributes of disease activity. While recognising that an analysis based on individual patient data might provide additional insight, the lack of consistent biological markers for high risk of recurrence (for example, permeability studies) in previous studies might make the approach irrelevant.
The issue as to whether or not to initiate maintenance treatment with either mesalazine or azathioprine remains a matter for discussion between patient and physician.
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