lumenal disease: response and remission
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Management of Perianal Fistula: Remicade, Surgery or Both
Management of Perianal Fistula: Remicade, Surgery or Both
Miguel Regueiro, M.D.
Associate Professor of Medicine
Co-Director, Inflammatory Bowel Disease Center
University of Pittsburgh Medical Center
Clinical Vignette
• 19 yo male with a 3 year history of Crohn’s ileocolitis presents with perianal pain.
• Meds: Mesalamine 4g and Entocort 9mg
• A recent colonoscopy revealed active Crohn’s disease in the rectum and ileum.
• On PEx: indurated perianal fistula draining purulent fluid.
• How common are fistula in Crohn’s ds?
Fistula: Definition
• A communication between two epithelial-lined organs.
• Lifetime risk of fistula in CD:30%
SmallIntestine Large
Intestine(Colon)
Fistula
Fistula
Percentage of Fistulae by Type
54%
13%
9%
24%
Schwartz DA et al. Gastroenterology. 2002;122:875.
Perianal
Other
Rectovaginal
Enteroenteric
Clinical Case: Continued
• 19 yo with Crohn’s disease and perianal fistula.
• Metronidazole 500mg po bid and Ciprofloxacin 500mg po bid are started.
• What now?– 6MP/Azathioprine– Infliximab?– EUA and seton?– Combination Seton and Medication?
Therapeutic Options for Perianal Fistulae in CD
• Antibiotics
• Immunomodulators– Azathioprine (AZA)/
6-mercaptopurine(6-MP)
– Cyclosporine– Methotrexate (MTX)
• Infliximab
• Tacrolimus*
Possible Efficacy Proven EfficacyNo Efficacy
• Aminosalicylates
• Corticosteroids
Sandborn W et al. Gastroenterology. 2002;122:A81. Abstract 670.Schwartz DA et al. Ann Intern Med. 2001;135:906.*Preliminary data
REMICADE® (infliximab) For the Treatment of Fistulas in Patients with Crohn's Disease
REMICADE® (infliximab) For the Treatment of Fistulas in Patients with Crohn's Disease
Present D, et al. N Engl J Med. 1999;340:1398–1405.
IN04
311
REMICADE® (infliximab) in Patients with Fistulizing Crohn’s Disease
Study DesignStudy Design
0 2 6 10 14 18Weeks
10 mg/kg
5 mg/kg
Placebo
Randomize to3-dose Treatment
8
Present D, et al. N Engl J Med. 1999;340:1398-1405.IN04
311
REMICADE® (infliximab) in Patients with Fistulizing Crohn’s Disease
9
Primary Endpoint: Primary Endpoint: 50% Reduction in Draining Fistulas50% Reduction in Draining Fistulas
P=0.002
P=0.021
*Placebo=Conventional Therapy
*
Present D, et al. N Engl J Med. 1999;340:1398-1405.IN04
311
REMICADE® (infliximab) in Patients with Fistulizing Crohn’s Disease
Perianal Fistula Case StudyPerianal Fistula Case Study
Pretreatment 2 Weeks
10 Weeks 18 weeks
10
Present D, et al. N Engl J Med. 1999;340:1398-1405.
IN04
311
A Randomized Double-blind, Placebo-controlled Trial of REMICADE®
(infliximab) in the Long-Term Treatment of Patients with Fistulizing Crohn’s Disease
A Randomized Double-blind, Placebo-controlled Trial of REMICADE®
(infliximab) in the Long-Term Treatment of Patients with Fistulizing Crohn’s Disease
Sands BE, et al. N Engl J Med. 2004;350:876-885.
IN04
311
Study Design Through Week 54
Evaluation at Week 54
All Patients, n=296Infusion
Week 0 REMICADE® (infliximab) 5 mg/kgWeek 2Week 6
Week 14 Responders n=177 (65%)
Nonrespondersn=96 (35%)
Week 22
PlaceboMaintenance
n=90
REMICADE 5 mg/kgMaintenance
n=87
REMICADE5 mg/kg
q 8 weeks
REMICADE10 mg/kgq 8 weeks
Week 30
Week 38
Week 46
23 patients discontinued
12ACCENT IIACCENT IIIN
0431
1
Endpoint Placebo Infliximab 5 mg/kg p
Median time to loss of response* (>50% reduction from baseline in number of draining fistulae)
14 wk >40 wk 0.0001
Complete responseat Week 30* (no draining fistulae)
27% 48% <0.002
Complete responseat Week 54 (no draining fistulae)
22% 38% 0.02
Infliximab Maintenance Therapyin Fistulizing CD: Results
Infliximab Maintenance Therapyin Fistulizing CD: Results
Sands B et al. Gastroenterology. 2002;122:A81. Abstract 671.
Clinical Vignette: continued
• Pt receives 1 week of Cipro/Metronidazole and undergoes and EUA.
• Surgeon finds a suprasphincteric fistula with abscess. The abscess is drained and a seton is placed.
• Infliximab 0,2,6 mg/kg is administered. Shortly before the third infliximab dose the fistula stops draining and the track is “tight” on the seton. The seton is removed.
• Does EUA with seton prior to infliximab improve fistula healing?
Treatment of Perianal Fistulizing CD with Infliximab Alone or as an
Adjunct to EUA and Seton Placement
Treatment of Perianal Fistulizing CD with Infliximab Alone or as an
Adjunct to EUA and Seton Placement
Regueiro M, Mardini H. Inflamm Bowel Dis 2003;9(2):98-103.
Study Aims
•To compare the rate of perianal fistula healing, relapse rate and time to relapse in patients treated with infliximab alone or as an adjunct to EUA and seton placement.
Methods• Patients with Crohn’s disease who completed at least
three infusions of infliximab (5mg/kg at 0,2,6 wks) for actively draining perianal fistula were evaluated.
• No patient received maintenance infliximab (q8wk).
• All patients had at least 3 months of follow-up after induction doses.
Definition of Fistulas and Response• Fistula classification:
– Complex: multiple external fistulas, involvement of anal sphincter, or extension of track above dentate line.
– Simple: Single and in-ano.
• Response and Recurrence:– Initial response: complete closure and cessation of
drainage within 3 mos of induction infliximab.– Recurrence: re-opening of external fistula track with
active drainage.
Results: Baseline Characteristics• 109 patients with CD treated with infliximab.
• 32 patients received 3 doses for perianal fistula and had at least 3 mos f/u after third dose
– 9 pts with EUA and seton prior to infliximab – 23 pts received infliximab without an EUA
• No difference between groups in terms of age, gender, smoking, concomitant medications, duration of CD or fistula, or type of CD or fistulas.
Perianal Fistulae: Parks’ Classification System
A Superficial fistula
B Intersphincteric fistula
C Transsphincteric fistula
D Suprasphincteric fistula
E Extrasphincteric fistula
Parks AG et al. Br J Surg. 1976;63:1.Schwartz DA et al. Ann Intern Med. 2001;135:906.
E CA B
D External anal sphincter
Simple Fistula with Seton
Seton/Infliximab vs. Infliximab AloneEUA + Seton then
infliximabInfliximab
alone
Fistula healing 100% 82.5%
Recurrence rate 44% 79%
Recurrence interval 13.5 mo 3.6 mo
Response by Type of Fistula
• Simple: 12 patients with simple fistula
• Complex: 20 patients with complex fistula
Simple Fistula: Response and Recurrence Rates
Infliximab EUA and Infliximab
56
33.3
100 100
0
20
40
60
80
100
120
Response Recurrence
Pati
en
ts (
%)
p= 1.000
p=0.232
Simple Fistula: Mean Time to Recurrence
5.2
15
0 2 4 6 8 10 12 14 16
Mean Time to Recurrence in Months
Infliximab EUA and Infliximab
Complex Fistula with Setons
Complex Fistula: Response and Recurrence Rates
Infliximab EUA and Infliximab
71.5
100100
50
0
20
40
60
80
100
120
Pa
tie
nts
(%
)
p= 0.026 p= 0.036
Complex Fistula: Mean Time to Recurrence
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Mean Time to Recurrence in Months
13
2.1
Infliximab EUA and Infliximab
Conclusions• EUA with seton placement significantly improves the rate and duration
of fistula response in CD patients subsequently treated with infliximab.– Simple fistula may not require EUA prior to infliximab.– Complex fistula should undergo EUA and seton placement prior to
infliximab.
• Role of EUA in patients receiving maintenance infliximab (q 8 wks) is unclear.
• High rate of non-healing fistula on EUS: seton prior to infliximab may lead to complete healing of tracks.
EUS to guide combined medical and surgical therapy
• 21 pts with perianal fistula treated with infliximab, azathioprine, and cipro. All had baseline EUS and where appropriate EUA and seton placement.
• 86% had complete response (median 10.6 weeks)
• 48% had persistent fistula activity on EUS
• 52% had NO persistent fistula activity on EUS and 7 pts were able to stop infliximab and maintain closure
• EUS may allow better guidance of medical and surgical therapy of fistula.
Schwartz DA IBD. 2005;11:727-32
EUS/MRI/EUA
Fistula Type?
High Trans-, Supra-, or Extrasphincteric
or abscess
Low Trans- or Intersphincteric or
abscess
Superficial
Fistulotomy+ Short Course
of Abx
Noncutting Seton AbxAZA/6-MP ± Infliximab
Failure
Observe
Failure
Maintenance Therapy With AZA/6-MP or
Infliximab
Substitute Tacrolimus/Cyclosporine for
Infliximab
Failure
Definitive Surgery:Proctectomy
Perianal FistulaTherapy
Physical exam & colonoscopy
Single fistula Multiple (complex) fistula or abscess
No rectal inflammation
Rectal/colon inflammation
EUA with seton
Cipro/Flagyl± fistulotomy
Cipro/Flagyl, AZA/6MPor infliximab
6MP/AZA and infliximab
Proctectomy or colectomy with colostomy or ileostomy
Failure
Fai
lure
Failure
Perianal FistulaTherapy
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