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Multimodal treatment improves outcomes in Crohn’s patients with perianal fistulas
Using a multimodal approach that included a combination of medical therapies, as well as surgical intervention, helped improve outcomes in patients with Crohn’s disease with perianal fistula, according to research published in Alimentary Pharmacology & Therapeutics.
Shaji Sebastian, MD, FRCP, from the inflammatory bowel disease unit at Hull & East Yorkshire Hospitals in the United Kingdom, and colleagues wrote that even with advances in treatments for CD, the cumulative probability of developing perianal fistulas (CD-pAF) has remained steady at 16.9% and 28.3% at 10 and 20 years following diagnosis, respectively.
“Despite the introduction of multiple newer effective strategies for luminal CD, CD-pAF patients even now present challenging clinical scenarios by either failing to respond to the therapeutic approaches or failing to sustain responses in those who initially improve following therapies such as antitumor necrosis factor alpha agents,” they wrote. “Management approaches for CDpAF patients remain one of the major unmet needs in CD.”
In a multinational, multicenter trial, Sebastian and colleagues sought to explore the impact of multimodal treatment in CD-pAF on recurrence rates and the need for repeat intervention.
Of 253 total patients, 65% underwent a multimodal approach that included a combination of medical treatments — including anti-TNF, immunomodulators and antibiotics — and a surgical approach that included examination under anesthesia and seton drainage at the time of their diagnosis.
Investigators found that this approach lead to complete fistula healing in 52% of patients and reduced the need for radical surgery (OR = 0.21; 95% CI, 0.05–0.81).
Sebastian and colleagues also found that multimodality treatment (OR = 0.35; 95% CI, 0.17–0.57), seton removal (OR = 0.09; 95% CI, 0.027–0.3), therapy with Remicade (infliximab, Janssen; OR = 0.19, 95% CI, 0.06–0.64), and therapy with Humira (adalimumab, AbbVie; OR = 0.12; 95% CI, 0.0260.56) were all predictive of avoiding repeat surgery.
Conversely, they found that proctitis and steroid use increased the risk for needing repeat or radical surgery.
Sebastian and colleagues wrote that a multimodal approach might be the best treatment in the short term for patients with CD-pAF because it helps them avoid repeat surgery.
“Only 32% of patients included in this study required repeat perianal fistula-related surgical intervention,” they wrote. “Furthermore, more radical surgery was avoided in most patients with diverting stoma; proctectomy was only required in 7.5% and 2.5% of patients, respectively.” – by Alex Young
Disclosures: Sebastian reports receiving research grants from Takeda, AbbVie, Warner Chilcott, Ferring, MSD, Biohit and Cellgene; serving on advisory boards of Takeda, AbbVie, Merck, Ferring, Pharmacocosmos, Warner Chilcott, Janssen, Falk Pharma, Biohot, TriGenix, Cellgene and Tillots Pharma; and receiving speakers fees from AbbVie, Janssen, Merck, Warner Chilcott and Falk Pharma. Please see the full study for all other authors’ relevant financial disclosures.