Sara Horst, MD, and David Schwartz, MD, on Refractory Perianal Crohn's Disease

Drs Sara Horst and David Schwartz from Vanderbilt University continue their podcast series on Crohn's disease in this discussion about the challenges of treating the patient with refractory Crohn disease and their approach to controlling the disease. 

You can hear the first podcast in this series, on managing patient expectations, here, and the second, on surgery and therapies, here. 

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 Sarah Horst and David Schwartz of Vanderbilt University will continue their conversation on perianal Crohn's disease, discussing the particular challenges of caring for the patient with refractory perianal Crohn's.

Dr. Sarah Horst: So great, we've got this person, they are trying to control perianal disease. We got them to the surgeon. We've got setons in. Frequently, what we, as gastroenterologists, see, we have this person comes in, they're already on infliximab, and they still have perianal symptoms. That becomes a very frustrating part for the patient and for us.

How do you deal with that situation, those patients?

Dr. David Schwartz:  That's very tough. There are lots of things that I want to make sure we go through. It's my checklist when I see these patients. The very first thing is to make sure that there was some imaging done — if there was imaging done initially and it's been a while, if it has been some recent imaging — to make sure that we really have control of all the fistulas that are present.

I have found over the years that a lot of the times when people are not doing quite as well as we would like on anti-TNFs, it's really because there wasn't any imaging done initially or the surgeon didn't really use the imaging and missed a fistula or two. That's allowing that to keep coming back.

If imaging was done and there was a variety of things addressed, and they're still not doing as well, then I'll check the drug level. We now know that people who have fistulizing disease need much higher doses of anti-TNF in particular to maximize outcomes. For luminal diseases, we know we're shooting for levels, in general, around 10, but for fistulizing disease,15 to 20 is average to maximize outcomes. There is a really interesting study that I saw that I think has been published at least electronically, which looked at anti-TNF levels within the fistula tract themselves. Even in patients with normal TNF levels, there wasn't any anti-TNF present within the fistula tract. Part of the reason why we need higher levels is it just takes much more higher levels of the medicine to get adequate levels within the fistula tract.

Dr. Horst:  That's really interesting. That might help patients, too, when they're like, "Why do you keep increasing this dose?" to talk to them about. One other thing I see sometimes, is the patient, they get a seton, they get on a biologic., they have control of drainage, and the seton comes out in 6 weeks or something. I've learned that that reimaging is especially important in those situations because in our practice, like you mentioned, we leave setons in for the patients. They keep them in for quite a while because we're trying to make sure we get adequate fistula and abscess drainage, fistula healing, and that's one thing I see as well.

Dr. Schwartz:  That's a great point. I wrote an editorial a few years back, and I called it, basically, the perianal equivalent of mucosal healing. Fistulas will stop draining very quickly with anti-TNF for instance, generally within 6 weeks. The drainage really slows down. But when we've done US studies or MRI studies at other centers, there's quite a bit of inflammation that persists for months. That would be the equivalent of someone being asymptomatic, but you're seeing active disease on colonoscopy.

We really want to wait and leave that to the setons, until there's the image documentation of a very quiescent disease to optimize the outcomes. Generally that takes, honestly, sometimes 5 or 6 months for some of the patients with complex disease. If you don't have access to a US or an MRI, then maybe just defaulting to leaving the setons in for that length of time is a reasonable alternative.

Dr. Horst:  I've taken to waiting as long as I can. When you reimage, do you have a timeframe that you typically do? Is it 4 or 6 months, 3, or just depends on the patient?

Dr. Schwartz:  My yardstick is if the drainage is slowed down significantly, and it's not purulent anymore, then usually I'll wait another month to give a little fudge factor there, and then reimaging at that point. Usually, at that point, the seton can come out.

Every once in a while, we're surprised by the inflammation that's there, and in that situation then, we'll recheck drug levels and see if there's something we can optimize.

Dr. Horst:  Got it.

Rebecca:  Thank you for joining us today. In their next podcast, Doctors Hurst and Schwartz are going to be discussing the use of immunomodulators, when to remove setons, and what's new on the horizon for therapies for perianal Crohn's disease.