David
Co-Founder
The article, "Medical Treatment Options for Perianal Crohn's Disease" by Sara N Horst and David A. Schwartz is found on pages 729-734 of the book, "Advanced Therapy in Inflammatory Bowel Disease" and is supported by 14 references. For any of you interested in the deeper medical side of Crohn's Disease, this book is fantastic but be warned, it is aimed at medical practitioners and is heavy reading. This thread will contain information I feel is useful in the article and I also open it up for discussion.
- The first symptoms of perianal Crohn's disease are usually pain and/or drainage.
- Medical treatment of perianal Crohn's works best if a surgeon has drained any abscesses and placed setons in any fistulae.
- Perianal fistula rates among people with Crohn's range between 17% and 43%.
- 54% of fistulas are in the perianal area.
- People with rectal inflammation are at the greatest risk of developing perianal Crohn's disease. One study showcased that 90% of people with perianal fistula had colon and rectal inflammation. Whereas 41% who had colon inflammation but rectal sparing had perianal fistula and only 12% of those with small bowel disease had perianal fistula.
- In one study, 35% of perianal fistula recurred and the mean closure time was 14 weeks. The mean recurrence time was 2.8 years and 21% required proctectomy.
- There are two classification schemes for perianal fistula. The Parks classification and the simple/complex classification.
- The Parks classification uses intersphincteric, transphincteric, suprasphincteric, extraspincteric, and superficial.
- Anti-TNF and immunosuppressive medications are effective for perianal disease.
- Antibiotics are commonly used for perianal disease as the deal with the sepsis and inflammation. Metronidazole and Ciprofloxacin are the most commonly used for 2-4 months.
- A study of metronidazole at 20mg/kg/day had all patients report a reduction in pain and tenderness and 83% had fistula closure. However, recurrence is common after discontinuation.
- A study of 52 patients had three groups. Antibiotics only, azathioprine added to antibiotics after 8 weeks, and antibiotics added to those already on azathioprine. At week 8, 50% had responded to antibiotics. At week 20, those who were also on azathioprine were more likely to maintain the response with a rate of 48% versus 15%.
- In a meta analysis of 70 patients, 54% of patients on azathioprine of 6-MP had perianal fistula closure versus 21% for placebo.
- IV Cyclosporine can be used as a bridge therapy with 83% of patients responding within 1-2 weeks.
- For patients with refractory perianal Crohn's disease, Tacrolimus has been shown to help 43% of patients versus 8% taking the placebo.
- Infliximab (Remicade) has been shown to be effective in perianal Crohn's disease. In one study, 55% of people on 5mg/kg and 38% of people on 10mg/kg versus 13% placebo had fistula closure. Mean closure time was 3 months.
- Adalimumab (Humira) had 39% of patients versus 13% experience fistula closure at week 56 in the CHARM trial. Of those who took the Humira, 90% maintained closure at 1 years and 60% at year 2.
- The author suggests utilizing the, "top down" approach for perianal Crohn's disease but stresses that surgical drainage of abscess and application of setons to fistula is of utmost importance.
- The first symptoms of perianal Crohn's disease are usually pain and/or drainage.
- Medical treatment of perianal Crohn's works best if a surgeon has drained any abscesses and placed setons in any fistulae.
- Perianal fistula rates among people with Crohn's range between 17% and 43%.
- 54% of fistulas are in the perianal area.
- People with rectal inflammation are at the greatest risk of developing perianal Crohn's disease. One study showcased that 90% of people with perianal fistula had colon and rectal inflammation. Whereas 41% who had colon inflammation but rectal sparing had perianal fistula and only 12% of those with small bowel disease had perianal fistula.
- In one study, 35% of perianal fistula recurred and the mean closure time was 14 weeks. The mean recurrence time was 2.8 years and 21% required proctectomy.
- There are two classification schemes for perianal fistula. The Parks classification and the simple/complex classification.
- The Parks classification uses intersphincteric, transphincteric, suprasphincteric, extraspincteric, and superficial.
- Anti-TNF and immunosuppressive medications are effective for perianal disease.
- Antibiotics are commonly used for perianal disease as the deal with the sepsis and inflammation. Metronidazole and Ciprofloxacin are the most commonly used for 2-4 months.
- A study of metronidazole at 20mg/kg/day had all patients report a reduction in pain and tenderness and 83% had fistula closure. However, recurrence is common after discontinuation.
- A study of 52 patients had three groups. Antibiotics only, azathioprine added to antibiotics after 8 weeks, and antibiotics added to those already on azathioprine. At week 8, 50% had responded to antibiotics. At week 20, those who were also on azathioprine were more likely to maintain the response with a rate of 48% versus 15%.
- In a meta analysis of 70 patients, 54% of patients on azathioprine of 6-MP had perianal fistula closure versus 21% for placebo.
- IV Cyclosporine can be used as a bridge therapy with 83% of patients responding within 1-2 weeks.
- For patients with refractory perianal Crohn's disease, Tacrolimus has been shown to help 43% of patients versus 8% taking the placebo.
- Infliximab (Remicade) has been shown to be effective in perianal Crohn's disease. In one study, 55% of people on 5mg/kg and 38% of people on 10mg/kg versus 13% placebo had fistula closure. Mean closure time was 3 months.
- Adalimumab (Humira) had 39% of patients versus 13% experience fistula closure at week 56 in the CHARM trial. Of those who took the Humira, 90% maintained closure at 1 years and 60% at year 2.
- The author suggests utilizing the, "top down" approach for perianal Crohn's disease but stresses that surgical drainage of abscess and application of setons to fistula is of utmost importance.
