Opinion Review
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jul 7, 2021; 27(25): 3693-3704
Published online Jul 7, 2021. doi: 10.3748/wjg.v27.i25.3693
Approach to medical therapy in perianal Crohn’s disease
Abhinav Vasudevan, David H Bruining, Edward V Loftus Jr, William Faubion, Eric C Ehman, Laura Raffals
Abhinav Vasudevan, David H Bruining, Edward V Loftus Jr, William Faubion, Laura Raffals, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, United States
Eric C Ehman, Department of Radiology, Mayo Clinic, Rochester, MN 55905, United States
Author contributions: Vasudevan A was involved with developing the manuscript and writing the initial draft; Raffals L, Loftus EV Jr, Faubion W, Ehman EC and Bruining DH were involved with the critical revision of the manuscript for important intellectual content.
Conflict-of-interest statement: Loftus EV Jr has consulted for AbbVie, Allergan, Amgen, Arena, Boehringer Ingelheim, Bristol-Myers Squibb, Calibr, Celgene, Celltrion Healthcare, Eli Lilly, Genentech, Gilead, Iterative Scopes, Janssen, Ono Pharma, Pfizer, Sun Pharma, Takeda, and UCB; and has received research support from AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Genentech, Gilead, Janssen, Receptos, Robarts Clinical Trials, Takeda, Theravance, and UCB. Bruining DH—Medtronics: consulting agreement; Takeda: research support. Raffals L, Ehman EC, Faubion W and Vasudevan A have no disclosures.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Abhinav Vasudevan, BMed, FRACP, MPH, PhD, Doctor, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States. vasudevan.abhinav@mayo.edu
Received: February 26, 2021
Peer-review started: February 26, 2021
First decision: April 5, 2021
Revised: April 13, 2021
Accepted: June 2, 2021
Article in press: June 2, 2021
Published online: July 7, 2021
Processing time: 129 Days and 7.1 Hours
Abstract

Perianal Crohn’s disease remains a challenging condition to treat and can have a substantial negative impact on quality of life. It often requires combined surgical and medical interventions. Anti-tumor necrosis factor (anti-TNF) therapy, including infliximab and adalimumab, remain preferred medical therapies for perianal Crohn’s disease. Infliximab has been shown to be efficacious in improving fistula closure rates in randomized controlled trials. Clinicians can be faced with a number of questions relating to the optimal use of anti-TNF therapy in perianal Crohn’s disease. Specific issues include evaluation for the presence of perianal sepsis, the treatment target of therapy, the ideal time to commence treatment, whether additional medical therapy should be used in conjunction with anti-TNF therapy, and the duration of treatment. This article will discuss key studies which can assist clinicians in addressing these matters when they are considering or have already commenced anti-TNF therapy for the treatment of perianal Crohn’s disease. It will also discuss current evidence regarding the use of vedolizumab and ustekinumab in patients who are failing to achieve a response to anti-TNF therapy for perianal Crohn’s disease. Lastly, new therapies such as local injection of mesenchymal stem cell therapy will be discussed.

Keywords: Fistula; Biologics; Inflammatory bowel disease; Surgery; Stem cells; Infliximab; Ustekinumab

Core Tip: Early commencement of anti-tumor necrosis factor (anti-TNF) therapy in perianal Crohn’s disease is preferred over delaying treatment, although perianal sepsis should be treated first. Symptomatic remission remains the treatment goal, with radiographic healing an evolving target. Concomitant antibiotic therapy while initiating anti-TNF therapy is efficacious. Therapeutic drug monitoring and dose adjustment of anti-TNF therapy, targeting a higher trough level than what is routinely used for luminal disease, may improve treatment response. Ustekinumab may be efficacious in anti-TNF refractory individuals, although more studies are needed. Mesenchymal stem cell injection can be used in individuals who are refractory to anti-TNF therapy.