Use of Endoscopic Ultrasound to Guide Adalimumab Treatment in Perianal Crohnʼs Disease Results in Faster Fistula Healing

Wiese, Dawn M.; Beaulieu, Dawn; Slaughter, James C.; Horst, Sara; Wagnon, Julianne; Duley, Caroline; Annis, Kim; Nohl, Anne; Herline, Alan J.; Muldoon, Roberta L.; Geiger, Tim; Wise, Paul E.; Schwartz, David A.

doi:10.1097/mib.0000000000000409

Cited by 32 publications

(17 citation statements)

References 19 publications

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“…Three studies (3 retrospective reviews of prospectively collected data reported by the same first author, perhaps with overlapping populations, and examining treatment with some combination of an anti-TNF-α [agent not specified] plus azathioprine and/or antibiotics[ 24 - 26 ]) reported clinical remission rate and radiological remission rate, one retrospective study (examining fibrin glue with or without adult stem cells) included Magnetic resonance imaging (MRI) results as part of their definition of remission[ 27 ], and two studies (one prospective trial of adalimumab and one retrospective study examining infliximab plus other medications such as 6-mercatopurine, azathioprine, methotrexate, and/or antibiotics) provided rates for both clinical and endoscopic ultrasound-confirmed remission[ 28 , 29 ]. Overall, only a small proportion of patients with CD and CPF treated with anti-TNF-α (agent not specified) achieved radiological healing.…”

Section: Resultsmentioning

confidence: 99%

“…The proportion of adalimumab-treated patients that achieved complete cessation of drainage varied. The complete response rate after adalimumab treatment was 88% at 48 wk among a subset of nine patients enrolled in a randomised prospective study conducted in the United States (US) who underwent assessments by endoscopic ultrasound every 12 wk and was 73% among 11 control patients who received standard of care without endoscopic ultrasound[ 28 ]. Complete response was 28% among 38 CD patients with CPF at 12 mo in a retrospective multicentre study conducted in Spain[ 33 ].…”

Section: Resultsmentioning

confidence: 99%

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Burden and outcomes for complex perianal fistulas in Crohn’s disease: Systematic review

Panés

Reinisch

Rupniewska³

et al. 2018

WJG

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AIMTo systematically review the literature on epidemiology, disease burden, and treatment outcomes for Crohn’s disease (CD) patients with complex perianal fistulas.METHODSPubMed, Embase, and Cochrane were searched for relevant articles (published 2000-November 2016) and congress abstracts (published 2011-November 2016).RESULTSOf 535 records reviewed, 62 relevant sources were identified (mostly small observational studies). The cumulative incidence of complex perianal fistulas in CD from two referral-centre studies was 12%-14% (follow-up time, 12 years in one study; not reported in the second study). Complex perianal fistulas result in greatly diminished quality of life; up to 59% of patients are at risk of faecal incontinence. Treatments include combinations of medical and surgical interventions and expanded allogeneic adipose-derived stem cells. High proportions of patients experience lack of or inadequate response to treatment (failure and relapse rates, respectively: medical, 12%-73% and 0%-41%; surgical: 0%-100% and 11%-20%; combined medical/surgical: 0%-80% and 0%-50%; stem cells: 29%-47% and not reported). Few studies (1 of infliximab; 3 of surgical interventions) have been conducted in treatment-refractory patients, a population with high unmet needs. Limited data exist on the clinical value of anti-tumour necrosis factor-α dose escalation in patients with complex perianal fistulas in CD.CONCLUSIONComplex perianal fistulas in CD pose substantial clinical and humanistic burden. There is a need for effective treatments, especially for patients refractory to anti-tumour necrosis factor-α agents, as evidenced by high failure and relapse rates.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Burden and outcomes for complex perianal fistulas in Crohn’s disease: Systematic review

Panés

Reinisch

Rupniewska³

et al. 2018

WJG

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“…However, endoscopic ultrasound (EUS)76 can provide onsite adjunct assessment of perianal fistulas, sinuses, abscesses and demonstrate local lymphadenopathy. The same endoscope may be used in vaginoscopy to assess rectovaginal or pouch-vaginal fistulas.…”

Section: The Role Of Endoscopy In the Management Of Perianal Fistulasmentioning

confidence: 99%

Modern management of perianal fistulas in Crohn’s disease: future directions

Kotze

Shen

Lightner

et al. 2018

Gut

130

104

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Perianal fistulae in patients with Crohn's disease (CD) can be associated with significant morbidity resulting in negative impact on quality of life. The last two decades have seen significant advancements in the management of perianal fistulas in CD, which has evolved into a multidisciplinary approach that includes gastroenterologists, colorectal surgeons, endoscopists and radiologists. Despite the introduction of new medical therapies such as antitumour necrosis factor and novel models of care delivery, the best fistula healing rates reported with combined medical and surgical approaches are approximately 50%. More recently, newer biologics, cell-based therapies as well as novel endoscopic and surgical techniques have been introduced raising new hopes that outcomes can be improved upon. In this review, we describe the modern management and the most recent advances in the management of complex perianal fistulising CD, which will likely impact clinical practice. We will explore optimal use of both older and newer biological agents, as well as new data on cell-based therapies. In addition, new techniques in endoscopic and surgical approaches will be discussed.

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“…Anti-TNF therapy has been shown to be an effective treatment for closure of perianal fistulizing CD[65]. Infliximab or adalimumab step up therapy for CD guided by assessment of disease severity by anal ultrasound is associated with a high rate of fistula closure[86]. …”

Section: Surgical Options For Perianal CDmentioning

confidence: 99%

Indications and surgical options for small bowel, large bowel and perianal Crohn's disease

Toh¹,

Stewart²,

Rickard³

et al. 2016

WJG

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Despite advancements in medical therapy of Crohn’s disease (CD), majority of patients with CD will eventually require surgical intervention, with at least a third of patients requiring multiple surgeries. It is important to understand the role and timing of surgery, with the goals of therapy to reduce the need for surgery without increasing the odds of emergency surgery and its associated morbidity, as well as to limit surgical recurrence and avoid intestinal failure. The profile of CD patients requiring surgical intervention has changed over the decades with improvements in medical therapy with immunomodulators and biological agents. The most common indication for surgery is obstruction from stricturing disease, followed by abscesses and fistulae. The risk of gastrointestinal bleeding in CD is high but the likelihood of needing surgery for bleeding is low. Most major gastrointestinal bleeding episodes resolve spontaneously, albeit the risk of re-bleeding is high. The risk of colorectal cancer associated with CD is low. While current surgical guidelines recommend a total proctocolectomy for colorectal cancer associated with CD, subtotal colectomy or segmental colectomy with endoscopic surveillance may be a reasonable option. Approximately 20%-40% of CD patients will need perianal surgery during their lifetime. This review assesses the practice parameters and guidelines in the surgical management of CD, with a focus on the indications for surgery in CD (and when not to operate), and a critical evaluation of the timing and surgical options available to improve outcomes and reduce recurrence rates.

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Use of Endoscopic Ultrasound to Guide Adalimumab Treatment in Perianal Crohnʼs Disease Results in Faster Fistula Healing

Abstract: Rectal EUS-guided ADA therapy for CD perianal fistulas showed an initial benefit at 24 weeks, which was lost at week 48. This is likely due to small sample size and higher fistula closure in the controls. However, the faster rate of fistula resolution is a clinically significant finding.

Cited by 32 publications

References 19 publications

Burden and outcomes for complex perianal fistulas in Crohn’s disease: Systematic review

Burden and outcomes for complex perianal fistulas in Crohn’s disease: Systematic review

Modern management of perianal fistulas in Crohn’s disease: future directions

Indications and surgical options for small bowel, large bowel and perianal Crohn's disease

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