Optimized timing of using infliximab in perianal fistulizing Crohn's disease

Abstract

Infliximab (IFX), as a drug of first-line therapy, can alter the natural progression of Crohn’s disease (CD), promote mucosal healing and reduce complications, hospitalizations, and the incidence of surgery. Perianal fistulas are responsible for the refractoriness of CD and represent a more aggressive disease. IFX has been demonstrated as the most effective drug for the treatment of perianal fistulizing CD. Unfortunately, a significant proportion of patients only partially respond to IFX, and optimization of the therapeutic strategy may increase clinical remission. There is a significant association between serum drug concentrations and the rates of fistula healing. Higher IFX levels during induction are associated with a complete fistula response in these patients. Given the apparent relapse of perianal fistulizing CD, maintenance therapy with IFX over a longer period seems to be more beneficial. It appears that patients without deep remission are at an increased risk of relapse after stopping anti-tumor necrosis factor agents. Thus, only patients in prolonged clinical remission should be considered for withdrawal of IFX treatment when biomarker and endoscopic remission is demonstrated, especially when the hyperintense signals of fistulas on T2-weighed images have disappeared on magnetic resonance imaging. Fundamentally, the optimal timing of IFX use is highly individualized and should be determined by a multidisciplinary team.

Keywords: Infliximab; Crohn’s disease; Perianal fistula; Optimization; Trough level; Deep remission

Core tip: The long-term outcomes of infliximab in the treatment of perianal fistulizing Crohn’s disease are unfavorable, due to loss of response. The optimization of the therapeutic strategy may increase clinical remission. Higher infliximab concentrations during induction are associated with a complete fistula response. Only patients in prolonged clinical remission should be considered for withdrawal of infliximab when biomarker, endoscopic and radiological remission is demonstrated. Fundamentally, the optimal timing of infliximab use is highly individualized and should be determined by a multidisciplinary team.