Optimal Management of Perianal Disease in Crohn’s Disease

Crohn’s disease is an inflammatory disease of the gastrointestinal tract. To learn more about perianal disease in Crohn’s disease, Medscape spoke with David A. Schwartz, MD, professor of medicine and director of the Inflammatory Bowel Disease Center at Vanderbilt University Medical Center. Read on for his insights. The interview has been edited for length and clarity.
Perianal disease is essentially the Crohn’s affecting the patients perinium. The most common manifestation is a perianal fistula which is essentially a tunnel that connects the rectum to the perianal skin or to another organ from the inflammation caused by Crohn’s.
It occurs in about one quarter of patients affected by Crohn’s disease. 
The main risk factor is having inflammation in the rectum. Previous studies have shown that if you have proctitis related to Crohn’s, your chance of developing a fistula in your lifetime is close to 100%. In patients who have rectal involvement, you want to be very careful because the risk of developing fistulas is so high. 
There are a lot of guidelines that have been published, and I have been part of them. The one that I follow the most or more closely is the one that was put out by the American Gastroenterological Association (AGA). Essentially, the guidelines call for imaging to assess fistula anatomy and then doing multimodality therapy with a gastroenterologist and a surgeon to help control the sepsis and optimize medical therapy.
We have learned that having both a surgeon and a gastroenterologist treat these patients leads to the best outcomes. The surgeon’s role in this situation is to essentially clean up any purulent material that might be present and place setons in any fistulas that are there. The reason that is helpful is that it allows the gastroenterologist to control healing while the medicine works. Our therapies are very effective. 
A fistula is essentially a tunnel, and your body wants to close the external and internal openings of that tunnel as quickly as possible because they shouldn’t be there. That process is accelerated with our advanced therapies. If you don’t have a seton in place or you don’t clean up all the purulent material present, it can lead to an abscess or recurrent fistula formation. Using setons allows the fistula healing to be controlled and ensures the medicine works optimally.
Usually, treatment is a combination of antibiotics and other drugs. When an antibiotic is used, it is ciprofloxacin or metronidazole to treat the infectious part of it; those drugs also have some anti-inflammatory properties. Then you use an advanced therapy to help control the Crohn’s-related inflammation. Most of the time, that is going to be an anti–tumor necrosis factor (TNF) therapy, such as infliximab (Remicade) or adalimumab (Humira). If someone has already been on those medications before and have refractory disease, then we will use a medicine like upadacitinib (Rinvoq). Upadacitinib is a JAK inhibitor, a newer medication, that has been shown to be effective for refractory disease.
Anti-TNF therapies are usually very well tolerated. A small percentage of patients will have an increased risk for infection. Very, very rarely, there is a risk for lymphoma associated with anti-TNF therapy, and the risks are very similar with Janus kinase (JAK) inhibitors. 
The one thing with JAK inhibitors is that there is a particularly increased risk for viral infections and reactivation of shingles. So you want to make sure that we have that patient who is at risk be vaccinated for shingles to help reduce or eliminate that risk. 
No. Crohn’s patients in general are at risk for shingles, and any immune suppression will increase your risk. Particularly with JAK inhibitors, that risk is elevated more.
Usually what we are asking the surgeons to do is clean up any abscess present with an incision and drainage procedure, or place setons to help control fistula healing. When medical therapy has failed the patient or the patient is mentally done with all that perianal disease involves, and they want to have more definitive surgery, then the surgeon will do something like a diverting ileostomy, a colectomy, or proctectomy.
It’s not as good as we would like it to be. When we look at the trials that have examined, for example anti-TNF therapy, which is our best agent for fistulas, usually two thirds of people will respond initially, but when you look over the course of the next year, only about 30%-40% of patients will be able to maintain fistula closure. We would like to be doing a lot better for our patients. There are some ideas as to why it’s not as effective as we would like. Perhaps we need higher drug levels when we are treating fistulizing disease. A lot of us now check for drug levels and push for higher drug levels with our anti-TNFs to optimize outcomes. But, in general, fistula healing has been disappointing with the agents we currently have available.
We have talked a lot about how we treat the fistula, but we haven’t talked about how to treat the whole patient. Patients are not just their fistulas. The manifestations of perianal disease lead to a lot of pain, incontinence, and social isolation, and as a result, there is a really high rate of depression and anxiety. There are also sometimes nutritional deficiencies, because people restrict their eating to help control their pain by not going to the bathroom as much. 
It takes a team approach to optimally treat the patient. So, you want to ideally have mental health providers available to help with that. You want to have nutritionists or dietitians to help with the dietary aspects to get the best outcomes for these patients. 
I think so often, we ignore the psychosocial side of things, and perianal disease in Crohn’s has such a tremendous negative impact on psychosocial health that it’s really important that is addressed as well to get the best outcomes. 
To patients with this condition, I would say a few things. It is important to talk to your partner so they know what is going on, and to understand some of the mental health aspects that can be part of this process. It’s also important to talk to your doctor and be very honest and open with him or her about what is going on. For example, it is very common to have fecal incontinence associated with this, because the disease process can damage the anal sphincter, and you should mention that to your doctor. Talk to your doctor about sexual dysfunction. There are resources available to help you with all those things. It’s important to be open with your doctor and partner so they can help you.
There aren’t a lot of good resources currently available, but the Crohn’s and Colitis Foundation has some great resources and support for patients, particularly with fistulizing disease. There are some online information at WebMD, the Mayo Clinic, and the Cleveland Clinic that patients can refer to. And now there is information on Medscape.
David A. Schwartz, MD, has disclosed the following relevant financial relationships: Served as a consultant for: AbbVie; Avobis Bio; BMS; Gilead; Janssen; Olympus; Takeda