Sara Horst, MD and David Schwartz, MD, on Surgery and Therapies for Perianal Crohn Disease

In this second podcast of a series on the care of patients with perianal Crohn disease, Dr Horst and Dr Schwartz discuss when to involve a surgeon and the preferred medical therapies used to treat this complication of IBD.

You can hear the first podcast in this series, on managing patient expectations, here, and listen to other podcasts in the series 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

Welcome to another podcast from the Gastroenterology Learning Network. Today, doctors Sarah Horst and David Schwartz of Vanderbilt University continue their conversation on the care of patients with perianal Crohn's disease. They're going to discuss when to bring in a surgeon and what therapies work best for these patients.

Sara Horst:  When you're dealing with someone, especially when they're first diagnosed, how early do you get the surgeons involved, and how does that work?

David Schwartz:  Now, it's really standard-of-care, and I think the earlier you get them involved, the better the patient does. Studies have been done around the time when Remicade first came out where, if the patients had been examined and with anesthesia had setons placed before we started the biologics, they did way better.

About half the chance of having another recurrent fistula happened during treatment. What we'd normally do is after diagnosis we want to fully assess them, and then we send them immediately to our surgeon to use that information to clear up any sepsis that's there to really maximize the benefit of our medications.

Sara:  Yeah, I think that also I became more comfortable as I was practicing a little bit more in talking about what they might expect when they go to the surgeon, like explaining what a seton is and how long they might have that in, so that they're not caught off-guard when they go to make that surgery appointment or start hearing these words.

David:  It's helpful to be in a place where you have easy access to the colorectal surgeons, and we really work together as a team. I know that's not always the case. A lot of times, it requires a patient going across town to a different doctor's appointment.

It can be a little bit daunting, and there can be a time delay, so having that close relationship with the surgeon's super helpful.

Sara:  When we talk about treatment, let's think about that person that's first diagnosed. What do you consider best medical management? What would you start someone on if they get diagnosed with perianal Crohn's?

David:  I think the very first step, even before we get patients on therapy, is to get that assessment of their disease and to get some imaging modality, so you get a road map of what's going on in their bottom. You need to really make sure you get control of everything, drain any purulence that's there, and make sure you control fistula healing, before we start any of this.

Even antibiotics will allow things to heal very quickly. Unless you have that control, you set the patient up for a recurrent fistula track. We do that first, get them to see the surgeon, and get that examiner to do anesthesia.

Then, particularly in people who have not been on medicines before, we're going to probably want to start what we call our perianal combo therapy, which would be an anti-TNF, an immunomodulator, and an antibiotic.

I think the data with the anti-TNFs of all our biologics is the strongest in fistula healing and that tends to be the medicine I choose first.

Sara:  Definitely, and I use that all the time, I use perianal combination therapy when I talk to patients. I've learned from you, too, that I use antibiotics for a longer period of time than maybe I initially thought I would need to.

Instead of a 2-week course, I might use it a little bit longer. Is that something you're still doing?

David:  Yeah, my practice is generally to leave them on the antibiotic until about a week or 2 after I pull the seton, just to hopefully prevent any recurrent disease or abscess when the seton comes out. Because we keep setons probably longer than most, that probably winds up being about 4 to 6 months.

The reason I do that is there have been studies that looked at antibiotics and an anti-TNF or a placebo and an anti-TNF. Those that were on antibiotics did much better. It's really synergistic, as obviously the antibacterial properties, but also have some anti-inflammatory properties.

Then, in that particular study, once they stop the antibiotics, then really, the patients are regressed to the mean. I tend to leave them on longer to really maximize that benefit.

Sara:  Definitely. I think that was something that I learned. I use antibiotics a lot in perianal disease, too. Even like skin tags, like if those get irritated and act up, I think I've learned over time that that can be really helpful to control some of the inflammation in the area.

Sometimes, I even try to decrease the dose. Do you try to do that at all?

David:  More so with metronidazole than with the ciprofloxacin, just because the metronidazole, after a while, is not really well-tolerated.

Sara:  Yeah, that's the one I usually try to back down dosage-wise, if I can.

Watch for the upcoming podcast with Doctors Horst and Schwartz when they discuss how to work with patients who have refractory Crohn's disease and perianal complications. Thank you for joining us today.