Vermeire S, van Assche G, Rutgeerts P
Department of Gastroenterology, University hospital Leuven, Leuven, Belgium.
Aliment Pharmacol Ther. 2007 Jan 1;25(1):3-12. doi: 10.1111/j.1365-2036.2006.03134.x.
The natural course of Crohn's disease is characterized by flare-ups altered with periods of remission. The majority of Crohn's disease patients need surgery within 10 years of diagnosis. Major advances in treatment options over the past years have made our treatment goals more ambitious and modification of the natural course has become the ultimate endpoint.
To review the evidence of existing therapies for Crohn's disease for changing the natural history.
A Medline search was undertaken by using 'natural history', 'Crohn's disease', 'therapy' (corticosteroids, azathioprine, methotrexate, infliximab and enteral feeding), 'surgery', 'hospitalizations' and 'mucosal healing'.
Corticosteroids do not alter the disease course and maintenance therapy with corticosteroids should be avoided given their side effects. The immunomodulators azathioprine and methotrexate heal the mucosa but their onset of action is slow. Infliximab therapy introduces rapid mucosal healing and is associated with decreased hospitalizations and surgical interventions. Despite the fact that immunomodulators and infliximab are effective in maintaining clinical and endoscopic remission, there is little hard evidence at present that these therapies alter the natural history of the disease. The main reason being the fact that these therapies have so far been used only in refractory patients and that early initiation in the right patient is crucial in order to change the disease course.
Prospective studies should validate predictors of complicated disease and randomized studies in high-risk groups should be performed to answer if early introduction of immunomodulators or biological therapies slows down disease progression and alters natural history.
克罗恩病的自然病程特点为病情发作与缓解期交替出现。大多数克罗恩病患者在确诊后10年内需要接受手术治疗。过去几年治疗方案取得的重大进展使我们的治疗目标更具雄心，改变自然病程已成为最终目标。
综述现有克罗恩病治疗方法改变自然病程的证据。
通过使用“自然病程”“克罗恩病”“治疗”（皮质类固醇、硫唑嘌呤、甲氨蝶呤、英夫利昔单抗和肠内营养）“手术”“住院治疗”和“黏膜愈合”进行医学文献数据库检索。
皮质类固醇不会改变疾病进程，鉴于其副作用，应避免使用皮质类固醇进行维持治疗。免疫调节剂硫唑嘌呤和甲氨蝶呤可使黏膜愈合，但其起效缓慢。英夫利昔单抗治疗可使黏膜迅速愈合，并减少住院治疗和手术干预。尽管免疫调节剂和英夫利昔单抗在维持临床和内镜缓解方面有效，但目前几乎没有确凿证据表明这些治疗方法能改变疾病的自然病程。主要原因是这些治疗方法迄今仅用于难治性患者，且在合适的患者中早期开始治疗对于改变疾病进程至关重要。
前瞻性研究应验证复杂疾病的预测指标，应在高危人群中进行随机研究，以回答早期引入免疫调节剂或生物疗法是否会减缓疾病进展并改变自然病程。
