胃と腸42巻13号

2007年12月発行

今月の主題 新しい治療による炎症性腸疾患（IBD）の経過―粘膜治癒を中心に

主題

Crohn病における病型（経過）予測と治療方針―step-up治療 vs top-down治療

著者： 平田一郎¹

所属機関： ¹藤田保健衛生大学医学部消化管内科

ページ範囲：P.1812 - P.1818

文献概要

要旨　Crohn病(CD)は再燃と緩解を繰り返す疾患であるが，その臨床経過や予後は一様ではない．CD診断早期においてCDの予後や治療の反応性を予測できれば，その時点で適切な治療法の選択が可能である．このため，Vienna分類などいろいろな病型分類が提唱され検討されてきた．その結果，病態類型は病変部位類型に比して長期臨床経過の間に高率に変化するため病型分類を行ううえでの安定因子にはなりえないこと，CDの予後予測や治療の反応性予測には現行の分類以外の因子を加えた検討が必要であることが明らかとなった．CDの経過中に腸切除が必要となったり，狭窄型や穿通型の病態類型に進展したり，ステロイド依存性となったりする場合，その臨床経過は難治性であると言えよう．難治性CDを予測しうる因子として，若年発症，喫煙，広範な病変部位(小腸and/or大腸)，診断時からステロイド治療が必要，肛門周囲病変の存在，腸管外合併症の存在，などが挙げられる．CD診断時にこれらの因子が認められる場合は，早期にtop-down(TD)治療のような強力な治療を行い，病勢が重症化しないように配慮することが必要である．CDの病初期から免疫調節薬や生物製剤による強力な治療(TD治療)を行えばCDの自然史を変えうる可能性も考えられる．しかし，これを結論付けるにはまだ多くの解明すべき点も残されている．すなわち，軽症例にもTD治療を行うべきか，TD治療後にインフリキシマブ(IFX)のscheduled投与を行えばどうか，その際IFXに免疫調節薬〔アザチオプリン(AZA)など〕併用は必ずしも必要か，免疫調節薬長期投与の副作用をどう評価するか，TD治療後の長期(10年以上)経過例の集積，などについて検討が必要と考える．

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