Perianal Crohn's needs multidisciplinary approach: guidelines

Last Updated: 2015-03-19

By Megan Brooks

NEW YORK (Reuters Health) - Perianal fistulas are a common complication of Crohn's disease and effective management requires a multidisciplinary approach, according to clinical practice guidelines from the Crohn's & Colitis Foundation of America (CCFA).

Dr. David A. Schwartz, Director, Inflammatory Bowel Disease Center at Vanderbilt University Medical Center, Nashville, Tennessee, who worked on the guidelines, told Reuters Health, this has been a "multi-year effort by all of my co-authors. We wanted to put together a comprehensive multi-disciplinary guideline that reflects all of the different subspecialists that are needed to care for patients with this difficult problem."

Roughly 23% of patients with CD will develop at least one perianal fistula in their lifetime. They often experience persistent drainage, pain and incontinence, and reduced quality of life, the guideline authors say.

"The treatment paradigm for treating Crohn's perianal fistulas has changed rapidly since the development of anti-tumor necrosis alpha antibodies. The role of imaging and multispecialty care involving the gastroenterologist and the surgeon for these patients also continues to evolve," they point out.

The guidelines, which will be published online soon in a series of articles in the journal Inflammatory Bowel Diseases, cover imaging, and surgical and medical treatment of Crohn's perianal fistulas.

Imaging has become an "increasingly important" guide for gastroenterologists and surgeons caring for patients with CD, the authors note, and high-resolution magnetic resonance imaging and endoscopic ultrasound are currently the preferred techniques.

The medical treatment guideline reviews and rates the quality of evidence and therapeutic efficacy for various therapies for Crohn's perianal fistulas.

Of note, infliximab (A+ grade) has multiple high-quality randomized controlled trials with consistent results and "excellent" therapeutic efficacy for perianal fistula, the authors report.

Both adalimumab and certolizumab (A grade) have at least one high-quality RCT or multiple low-quality RCTs with consistent results and "excellent" therapeutic efficacy.

Thalidomide earns a "B" grade with multiple controlled observational studies with consistent results and "good" therapeutic efficacy. Grades on other agents include:

* Stem cell therapy: evidence C, efficacy good.

* Hyperbaric oxygen: evidence B-, efficacy fair.

* Mycophenolate mofetil: evidence B, efficacy good.

* Nutritional therapy (elemental diets and total parenteral nutrition: evidence C+, efficacy fair.

* Vedolizumab: evidence A-, efficacy good.

The surgery guideline takes a similar approach to grading various surgical treatment options.

"I believe these are the first (guidelines) put out on this topic by the CCFA. The American Gastroenterological Association (AGA) and the European societies also have similar guidelines on this topic," Dr. Schwartz told Reuters Health.

He said the overall take-home message for clinicians is that "patients with perianal Crohn's disease have a very complicated and debilitating manifestation of their IBD. Treatment and imaging options for these patients have improved greatly over the last 5-10 years. As a result, outcomes are much better but require a multidisciplinary approach to really maximize results and prevent complications."

What's practice-changing in the guidelines? "First, the overall idea of a multidisciplinary approach is important and though stressed in other guidelines is not done routinely in practice. Also, the use of imaging to assess and guide treatment is also somewhat novel," Dr. Schwartz said.

SOURCE: http://bit.ly/1AK2C50

Inflamm Bowel Dis 2015.