Stopping anti‐tumour necrosis factor therapy in patients with perianal Crohn’s disease

Mak, Joyce Wing Yan; Tang, WM; Yip, Terry Cheuk‐Fung; Ran, Zhi Hua; Shu, Wei; Ahuja, Vineet; Vuyyuru, Sudheer K.; Leung, Wai Keung; Hilmi, Ida; Limsrivilai, Julajak; Aniwan, Satimai; Lam, Belsy C Y; Chan, Kam Hon; Ng, Ka Man; Leung, Chi Man; Li, Michael K K; Lo, Fu Hang; Sze, Alex Shun Fung; Tsang, Steven Woon Choy; Hui, Aric Josun; Hartono, Juanda Leo; Ng, Siew C.

doi:10.1111/apt.15547

Cited by 10 publications

(14 citation statements)

References 33 publications

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“…Similar results were reported in a prospective study of 78 perianal CD patients, which found that maintenance therapy with immunosuppressants was not associated with a reduced risk of perianal relapse. 36 This is comparable to the finding by Pauline et al, who demonstrated that 84% of patients sustained a perianal response after IFX discontinuation at 18 months. 37 A prospective study also showed that maintenance of immunosuppressants after anti-TNF discontinuation was associated with perianal relapse (HR = 0.3).…”

Section: Discussionsupporting

confidence: 86%

“…Moreover, of 26 PFCD patients treated with anti-TNFs in this study, MRI showed complete healing (20, 28, and 30%, respectively), improvement (68, 72, and 65%) and no change (12, 0, and 0%) at 6, 12, and 18 months, respectively. 40 Another study also investigated whether 35.3% of patients who received radiological remission developed relapse at a median of 6 months after stopping anti‐TNF therapy, 36 showing that radiological assessment before stopping anti‐TNF therapy is critical for perianal CD. Second, IFX drug levels were not assessed during the follow-up.…”

Section: Discussionmentioning

confidence: 99%

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Perianal and Luminal Relapse Following Perianal Surgical Intervention in Crohn’s Disease

Deng

Xia

et al. 2021

IJGM

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Background and Aims: Fistula relapse occurs in 20-30% of patients with perianal Crohn's disease (PCD) despite optimal medico-surgical management. We aimed in this study to assess the rate of perianal and luminal relapse after surgically induced remission and to determine factors associated with fistula relapse. Methods: Consecutive perianal CD patients who achieved clinical remission after surgery for fistulising PCD from January 2013 to January 2019 were included. The cumulative probabilities of relapse-free survival were estimated using the Kaplan-Meier method. Results: A total of 130 patients were included. Sixty-six of 130 patients received infliximab (IFX) therapy after perianal surgery. After a median follow-up of 62 months (interquartile range [IQR]: 28-117 months), perianal relapse occurred in 30 of 64 (46.9%) nonbiological medication-treated cases and in 14 of 66 (21.1%) cases in the IFX therapy group. The cumulative probabilities of perianal relapse-free survival in patients with nonbiological treatment were 77.1% at 1 year, 54.6% at 3 years, and 30% at 5 years. The rates of survival without perianal fistula relapse in the IFX-treated group were 91.6%, 69.2%, and 59.3% at 1, 3 and 5 years, respectively. In patients treated with IFX after perianal surgery, discontinuation of IFX therapy (odds ratio [OR]=2.43, p=0.036), a penetrating CD phenotype (OR=4.324, p=0.019), and a complex perianal fistula (OR=3.392, p=0.026) were independently associated with perianal relapse in multivariate analysis. Conclusion: Infliximab therapy reduced the risk of perianal relapse after surgical remission in PCD patients compared with nonbiological treatment. However, approximately 40% of patients using infliximab experienced perianal relapse at 5 years, and patients who discontinued use of IFX or experienced a penetrating phenotype or a complex perianal fistula were associated with increased relapse rate.

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Section: Discussionsupporting

confidence: 86%

Section: Discussionmentioning

confidence: 99%

Perianal and Luminal Relapse Following Perianal Surgical Intervention in Crohn’s Disease

Deng

Xia

et al. 2021

IJGM

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“…The discontinuation of anti-TNF treatment is not recommended due to a high risk of relapse. Approximately half of the patients relapsed after anti-TNF was stopped, and one-third of patients with relapse required surgery [ 58 , 59 , 60 ].…”

Section: Medical Treatment For Fistulizing CDmentioning

confidence: 99%

The Optimal Management of Fistulizing Crohn’s Disease: Evidence beyond Randomized Clinical Trials

Wetwittayakhlang

Khoury

Hahn

et al. 2022

JCM

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Fistulizing Crohn’s disease (FCD) remains the most challenging aspect of treating patients with CD. FCD can occur in up to 30% of patients with CD and may lead to significant disability and impaired quality of life. The optimal treatment strategies for FCD require a multidisciplinary approach, including a combined medical and surgical approach. The therapeutic options for FCD are limited due to sparse evidence from randomized clinical trials (RCTs). The current recommendations are mainly based on post hoc analysis from RCTs, real-world clinical studies and expert opinion. There is variation in everyday clinical practice amongst gastroenterologists and surgeons. The evidence for anti-tumor necrosis factor therapy is the strongest in the treatment of FCD. However, long-term fistula healing can be achieved in only 30–50% of patients. In recent years, emerging data in the advent of therapeutic modalities, including the use of new biologic agents, therapeutic drug monitoring, novel surgical methods and mesenchymal stem cell therapy, have been shown to improve outcomes in achieving fistula healing. This review summarizes the existing literature on current and emerging therapies to provide guidance beyond RCTs in managing FCD.

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“…After 52 wk, 42% of patients had lost response in the infliximab maintenance group compared to 62% in the placebo group ( P < 0.001). Other retrospective studies have also found that over half of patients who cease anti-TNF therapy will have a clinical relapse with long-term follow-up, so stopping treatment either due to clinical remission or for other reasons is associated with a high risk of relapse[ 46 - 48 ].…”

Section: What Can Be Done To Optimize Response While On Anti-tnf Therapy For Perianal Crohn’s Disease?mentioning

confidence: 99%

Approach to medical therapy in perianal Crohn’s disease

Vasudevan¹,

Loftus²,

Faubion³

et al. 2021

WJG

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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.

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Stopping anti‐tumour necrosis factor therapy in patients with perianal Crohn’s disease

Cited by 10 publications

References 33 publications

Perianal and Luminal Relapse Following Perianal Surgical Intervention in Crohn’s Disease

Perianal and Luminal Relapse Following Perianal Surgical Intervention in Crohn’s Disease

The Optimal Management of Fistulizing Crohn’s Disease: Evidence beyond Randomized Clinical Trials

Approach to medical therapy in perianal Crohn’s disease

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