Approach to medical therapy in perianal Crohn’s disease

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.