The Uncertain Role of Immunomodulator Maintenance After Cessation of Anti-Tumor Necrosis Factor a Therapy

Reply. We thank Ripolles et al 1 for their comments about our article. We performed a prospective study of 29 patients with ileal or ileocolonic Crohn’s disease treated with anti–tumor necrosis factor agents; patients underwent small-intestine contrast ultrasonography (SICUS) before and after scheduled induction and maintenance therapy. As we mentioned, our group developed an instrument for assessing small-bowel Crohn’s disease and created a quantitative lesion index (sonographic lesion index for Crohn’s disease [SLIC]) using SICUS. 2 We observed significant improvements in SLIC scores and subscores after induction and maintenance therapy with anti–tumor necrosis factor agents, compared with before therapy. The SLIC scores, subscores, and index classes were improved significantly in patients with vs without clinical responses. 1 In our study we did not observe the complete resolution of lesions or subsequent normalization of SLIC scores and subscores. This observation may be explained by the fact that SLIC takes into account both the extent and severity of smallbowel damage, including stricturing and penetrating lesions as assessed by SICUS, and not only bowel wall thickness and color Doppler grade. 3 Furthermore, transmural healing is an evolving concept and we still do not know the exact definition or the clinical implication. As Ripolles et al mentioned, the complicated behavior of Crohn’s disease leads to greater structural damage of the bowel and a subsequently decreased response to treatment. Therefore, we suggest that differences among published studies are caused by the severity of patients enrolled and the timeframe of the sonographic