‘Perianal fistulas are preventable’ in pediatric Crohn’s with early anti-TNF therapy
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LAS VEGAS — Early treatment with tumor necrosis antagonist was linked to 79% reduced odds of patients with pediatric Crohn’s disease developing perianal fistulizing complications, noted a presenter at the Crohn’s & Colitis Congress.
“Perianal fistulas are very common, particularly in children with Crohn’s disease,” Jeremy Adler, MD, MSc, interim director at the Susan B. Meister Child Health Evaluation and Research Center, told Healio. “About one in three patients with childhood-onset Crohn’s disease develop perianal fistulas. These are very disturbing, cause major negative impact on quality of life, are difficult to treat and commonly reoccur. I believe that it would be far better to prevent perianal fistulas, if possible, than try to treat them once they develop.”
Prior retrospective studies from Adler and colleagues indicated that early use of anti-TNF therapy could reduce risk for developing perianal fistula complications. Based on these preliminary findings, the researchers prospectively collected data from the RISK cohort, consisting of children aged younger than 18 years with newly diagnosed CD from 28 sites across North America.
In their study, Adler and colleagues defined perianal fistulizing complications as a perianal fistula and/or abscess, excluding patients who developed complications at or before enrollment. Patients (n = 621) were divided into three groups — those who received no immunosuppression, those who received immunomodulators but not anti-TNF therapy, and those who received anti-TNF regardless of immunomodulator use.
The researchers then conducted a nearest neighbor propensity score trio matching, which matched patients across treatment categories based on gender, age at diagnosis, growth delay, deep endoscopic ulcers, small bowel involvement and colonic involvement. Using matched patients, Adler and colleagues examined the predicted likelihood of developing perianal fistulizing complications by treatment group and by time to follow-up of therapy initiation. The researchers used logistic regression analyses to estimate ORs for developing fistulizing complications.
According to study results, early anti-TNF therapy demonstrated 79% reduced odds for development of perianal fistulizing complications, and patients who exhibited perianal lesions had threefold increased odds for developing fistulizing complications.
“We found that early treatment with anti-TNF medications reduced the risk of perianal fistula,” Adler told Healio. “This corroborates our earlier findings and adds to the body of evidence that perianal fistulas are preventable. We also found that patients with perianal lesions — skin tags or fissures — were at a greatly increased risk for later perianal fistula development, [which] was consistent with previous retrospective studies.”
The researchers noted that although no other therapy prevented fistula development, patients who received anti-TNF therapy experienced growth delays more than patients who received immunomodulators or neither therapy (P = .002)
“This study lends evidence to support the early use of anti-TNF medications for pediatric Crohn’s disease,” Adler said. “I would especially support anti-TNF as first-line therapy in patients at high risk of perianal fistulas, such as those with perianal skin tags or fissures.”
He added: “Prospective studies are needed to clarify what are the optimal dosing and drug levels needed for perianal fistula prevention and for healing if someone does develop perianal fistulas.”
References:
- Adler J, et al. JAMA Netw Open. 2020;doi:10.1001/jamanetworkopen.2020.7378.
- Lawrence LS, et al. Inflamm Bowel Dis. 2022;doi:10.1093/ibd/izab109.
- Singer A, et al. Clin Gastroenterol Hepatol. 2021;doi:10.1016/j.cgh.2020.04.060.
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Adler J. Early tumor necrosis factor antagonist treatment prevents perianal fistula in pediatric Crohn’s disease. Presented at: Crohn’s & Colitis Congress; Jan. 25-27, 2024; Las Vegas.
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