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.

Doença de Crohn - uma revisão abrangente sobre etiologia, epidemiologia, diagnóstico, tratamento farmacológico e tratamento cirúrgico

“…A incorporação do TGN aos ácidos nucleicos resulta em efeitos citotóxicos do fármaco, podendo evoluir com importante leucopenia, trombocitopenia, anemia, e insuficiência de Brazilian Journal of Health Review, Curitiba, v. 7, n. 3, p. 01-13, may./jun., 2024 medula óssea. O monitoramento de infecções secundárias à imunossupressão e os riscos de sangramento devem ser feitos de forma periódica, assim como a avaliação de lesão hepática e renal (Veauthier;Hornecker, 2018, Vasudevan et al, 2021.…”

“…Além disso, essa classificação considera o comportamento da doença como não-estenosante e não-perfurante (B1), estenosante (B2) ou perfurante (B3), com ou sem doença perianal. Essas características são cruciais para determinar a abordagem cirúrgica adequada para cada paciente (Veauthier;Hornecker, 2018, Maria et al, 2021, Vasudevan et al, 2021.…”

“…Lesões gastroduodenais, embora raras, devem ser abordadas laparoscopicamente com antrectomia com Y-de-Roux ou gastrojejunostomia em caso de complicações e/ou refratariedade ao tratamento inicial. Finalmente, fístulas perianais são tratadas com fistulotomia e seton de drenagem, caso sejam sintomáticas, além de tratamento farmacológico adequado para seu grau de complexidade (Veauthier;Hornecker, 2018, Michael Christian Sulz et al, 2020, Maria et al, 2021, Vasudevan et al, 2021.…”

Surgical methods of fistula closure in fistulating perianal Crohn's disease

“…The major issue we identified with this study was the use of only adalimumab as an anti-tumour necrosis factor (TNF) agent. This meant that patients treated with infliximab, the most common anti-TNF α agent used in fistulating perianal Crohn's disease [3], were excluded from the study. This resulted in a lack of patients eligible for analysis and thus left the study significantly underpowered with a sample size approximately 75% less than their target.…”

Internal Orifice Alloy Closure: A New Procedure for Treatment of Perianal Fistulizing Crohn’s Disease

“…These characteristics leave patients with chronic immunosuppression and they need repeated surgery to treat the symptoms of the disease [ 4 , 5 ], but surgery cannot cure the disease [ 6 ]. More than a quarter of patients with CD develop perianal fistulizing Crohn’s disease (PFCD) [ 7 ], which has been treated with biologics and surgical procedures [ 8 ]. These patients experience an endless cycle of perianal abscess, pain, persistent drainage [ 9 ], recurrent perianal sepsis [ 10 ], and anal stricture [ 11 ], which cause ongoing medical costs, negative stress on the family, and a significant burden to the healthcare system [ 12 ].…”