The consensus on treating these patients, I think has not been thoroughly achieved. I think there's still some controversy about whether and which agents to use. The reason for that, I think, is that the results of control trials that have been done show that you do likely get some benefit, although the benefit is not as robust as any of us would like. Currently most patients are being offered post-operative prevention following surgery, most patients.

Patients who really ought to be offered post-operative prevention are those whose history suggests that they are frequent flyers, if you will. Patients who are coming back for surgeries repeatedly, have had fairly complex courses prior to the surgery that you're dealing with at that point.

The patients in whom prophylaxis, I think, really ought to be offered-and it really ought to be insisted upon-are patients whose disease has brought them back to the operating room table on multiple occasions. Other patients who have fistulizing or perforating disease, I think ought to be offered post-operative prophylaxis.

Patients in whom it ought to be more of a dialogue are patients who have a very limited segment, they've had disease for an extended period of time that has been relatively mild. And after years or even decades, culminated in a limited ileal resection, for example.

The agents that we're using for post-operative prophylaxis also may not be agents that the patients are willing to take or tolerate; that's also thrown into the discussion. For example, if you're going to be offering mesalamine to a patient following surgery, I think you need to be aware of the fact that mesalamine is really not an effective agent when we're dealing with active disease for fistulizing disease. So if they came in with fistulizing disease, you may want to veer away from mesalamine and suggest a systemic immunomodulatory agent, such as 6-mercaptopurine or azathioprine.

For a patient who is-has shown difficulty in adhering to a multi-pill regimen, such as mesalamine, it's unlikely that they're going to take 3 g of mesalamine a day, when they're asymptomatic. Adherence is going to be lower. That's another patient who you may want to consider a once-a-day dosing with either 6-mercaptopurine or azathioprine.

Other patients may not feel comfortable being on an immunomodulatory agent when they're feeling well and in a remission for a theoretical benefit in terms of prophylaxis. These are all part of the dialogue that you have with the patient. Most patients, in my experience, however, do accept the data even as mediocre results as you get with prevention, simply to have another element of control over the future and the natural history of their disease. So in terms of a consensus, I think the consensus is that you should offer it. And I think there's also a consensus that the data are not as strong as we'd like.