More than half of patients with perianal fistulizing Crohn’s disease relapsed within 5 years of stopping anti-TNF therapy, according to new research published in Inflammatory Bowel Disease.
While continuing immunosuppression therapy appeared to reduce the risk for relapse, investigators said their findings suggest that long-term use of biologics may be beneficial for the 37% of patients with perianal Crohn’s disease (CD) who develop fistulas.
“In perianal fistulizing CD, [anti-TNF alpha] withdrawal led to a high risk of relapse, with 4 out of 5 patients encountering either perianal or luminal relapse in the long-term,” the study authors wrote. “This high rate of relapses should make clinicians reconsider the ‘topdown’ strategy in this subgroup of patients.”
To determine the rate and risk factors for fistula relapse after anti-TNF discontinuation, investigators reviewed data on 213 patients with perianal fistulizing Crohn’s disease who were treated with anti-TNF therapy at the University Hospital of Rennes, France, between 1998 and 2016.
Forty-five patients discontinued anti-TNF therapy and were then followed for a median of 62 months, during which 24 patients experienced perianal relapse. Nineteen (79%) patients required a new surgical drainage.
Cumulative risk for perianal relapse was 24% at 1 year and 55% at 5 years. Additionally, 42% of patients experienced luminal relapse at 5 years, and the cumulative risk for 5-year global relapse was 67%.
The investigators were able to identify the following risk factors for perianal relapse: ileal localization at diagnosis (HR = 4.3; 95% CI, 1.2–12.1), persistent external fistula opening (HR = 2.4; 95% CI, 1.1–5.2), and use of a second line anti-TNF agent or previous dose optimization (HR = 4.6; 95% CI, 1.6–12.1). In contrast, continued use of immunosuppressants reduced the risk for relapse (HR = 0.3; 95% CI, 0.12–0.75).
Notably, all but one of the 24 patients achieved further remission with anti-TNF retreatment.
“Overall, the high risk of relapse (perianal and luminal) in this particular population of CD patients with perianal disease may suggest a benefit in continuing biologics long-term,” the authors concluded. – by Adam Leitenberger
Disclosures: Some of the authors reports financial ties to AbbVie, Ferring, MSD, Takeda, and Pfizer.