Sara Horst, MD, and David Schwartz, MD, on Current and Upcoming Treatments for Perianal Crohn Disease

In this podcast, Drs Sara Horst and David Schwartz wrap up their podcast series on perinanal Crohn disease with a discussion of existing and upcoming therapies and procedures.

Sara Horst, MD, is an associate professor of medicine and affiliated with the IBD Clinic at Vanderbilt University in Nashville, Tennessee, and also serves as Section Editor for IBD on the Gastroenterology Learning Network. David Schwartz, MD, is the director of the Inflammatory Bowel Disease Center and professor of medicine at Vanderbilt University.

TRANSCRIPT:

Rebecca Mashaw:  Welcome to another podcast from the Gastroenterology Learning Network. I'm your moderator, Rebecca Mashaw. Today, Doctors Sara Horst and David Schwartz of Vanderbilt University are going to conclude their conversation on caring for the patient with perianal Crohn's disease.

Among the topics they will touch on are the use of immunomodulators, the removal of setons, and what new therapies may be on the horizon for the treatment of this complex disease.

Dr. Sara Horst:  We talked briefly about immunomodulators. Is there one that you prefer? Is there a dosing strategy that you use?

Dr. David Schwartz:  I tend to use the azathioprine, just because it's a little easier to adjust, but 6-MP is fine. The one thing that has changed in my practice more recently is I used to leave people on immunomodulators for a lot longer. I tend to try to pull that off once I feel I've gotten the patient better and have adequate drug levels to minimize some of the risk with the immunomodulator.

Dr. Horst:  Yeah, definitely. Also, if I am pulling off an immunomodulator, I do think I'm vigilant about checking drug levels, at least in anti-TNF medications. Especially in a perianal disease, where I feel like our drug levels are so important. I'll do that. I, typically, probably do it about 3 to 6 months after I pull them, the immunomodulator. I don't know if that's what you do or...?

Dr. Schwartz:  That's exactly what I do. [laughs] I trained you well.

Dr. Horst:  Yes, you did. [laughs] Awesome. The next question is, when to take out the setons? You had mentioned you would really wait until after some sort of image, and then think about it, and that seems to be our practice. Is that reasonable?

Dr. Schwartz:  Wait for the drainage to slow down. Then, within a month, reimage them. If things look good at that time...We're doing most of ours with rectal US. The gastroenterologist is doing it. A lot of times, it's the gastroenterologist is taking care of the patient.

At the time of the US while they're still asleep and things look good, we'll just take the seton out while they're still sleeping. I will say that is one of the nice things about our surgical colleagues here. They really have allowed us to have free rein when it comes to that. That's not true in a lot of places. That does make a big difference in managing the patient.

Dr. Horst:  A takeaway is, even if you're not necessarily completely managing the seton, at least making sure the patient understands the expectation of this, maybe left in a little bit longer than typically would be. I'd love to get some kind of imaging to make sure this is the right thing to do to pull it out before that happens. I think involving the patient is important, too.

Dr. Schwartz:  The other thing that we haven't discussed, is sometimes we can't get people better, I mean, completely well. The seton staying in sometimes helps improve quality of life. Sometimes, after we image them and try to adjust things and do all these different things, it may be that the decision is to leave it in so that they don't develop an abscess and their quality of life stays good.

Dr. Horst:  Absolutely. We definitely have patients, they do have long-term setons. In my experience, it's especially the patient who, they had it removed and then had a recurrent abscess. They learned like, "Boy, managing this drainage is better with a seton than trying to pull it out too early."

Then, my last question is, what new therapies do we have on the horizon for perianal Crohn's disease since it is such a difficult thing to manage currently?

Dr. Schwartz:  This is definitely an unmet need in Crohn's treatment, for sure. There are a lot of things on the horizon, but the one that I'm most excited about are the adipose stem cell therapies. There is one that is approved in Europe based on a study called the ADMIRE study.

It, essentially, uses an allogenic adequate stem cell vein in patients with refractory fistulas or general fistulas that continue to drain, although they're on biologic therapy and their luminal disease is relatively quiescent. They come in. They have an exam under anesthesia and a curetage of the tract, and the setons placed to allow all the purulence to go out.

They come back about 2 weeks later and then they have the stem cells injected along the tract. The internal opening is closed to keep the stem cells within the tract itself. Using that protocol in the European study, over half the patients that have refractory fistulas, including most of them being on anti-TNFs in the past, we're able to completely close their fistula tract.

MRI was done and did not show any development of abscesses in those patients. That's super exciting, and it's being used clinically in Europe. We're one of the many centers in the US that's in the ADMIRE II trial that's, hopefully, going to show benefit in this country as well, and lead to approval. That is really the thing I'm most excited for.

I sometimes tend to talk about that too much to my patients who have refractory fistulas, but I think it helps give them a light at the end of the tunnel. There is this therapy that's, hopefully, going to be available very soon that can offer some benefit for those that are still struggling despite being on maximal therapy.

Dr. Horst:  Absolutely, it's such an exciting possible treatment that's coming. I, for sure, talk about it as well. It's exciting to be part of the trial. Hopefully, we'll see good results for our patients in the next few years. Thank you so much for talking about this difficult aspect of Crohn's disease, perianal disease, and I really appreciate your time. Thank you.

Dr. Schwartz:  Thanks, Sara. I appreciate it.

Rebecca:  Thank you for joining us today for this podcast. We hope you have found this series on perianal Crohn's disease to be informative and helpful to you in your practice. For more podcasts, visit the Gastroenterology Learning Network.