Pharmacological management of Crohn's disease of the pouch - a phenotype-based review.

INTRODUCTION: Crohn's-like disease of the pouch (CLDP) is an important long-term complication following ileal pouch-anal anastomosis (IPAA) for ulcerative colitis, associated with significant morbidity, impaired quality of life, and increased risk of pouch failure. Diagnosis remains challenging, in part due to heterogeneity in diagnostic criteria, and management is largely phenotype-driven and requires a multidisciplinary approach integrating medical, endoscopic, radiologic, dietary, and surgical therapies. AREAS COVERED: This narrative review is based on a literature search of PubMed and Scopus up to May 2026. The review summarizes the current evidence regarding pharmacological management of CLDP, including antibiotics, corticosteroids, immunomodulators, biologic therapies, and small molecules, alongside emerging data regarding dietary, endoscopic, and surgical interventions. Observational evidence suggests anti-TNF and interleukin-directed therapies demonstrate the strongest effectiveness signals, particularly in penetrating and fibrostenotic phenotypes, while vedolizumab may be most efficacious in inflammatory-predominant disease. However, interpretation remains limited by the absence of randomized controlled trials, inconsistent diagnostic criteria, heterogeneous phenotype composition, and the lack of phenotype-specific outcome reporting. EXPERT OPINION: Future progress in the field will depend on development of standardized diagnostic criteria, routine phenotype-specific outcome reporting, phenotype-based treatment algorithms, and prospective multicenter studies to better define optimal therapeutic sequencing and long-term pouch outcomes.