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Crohn's disease patients with perianal fistulas (PF) or a history of them had greater disease burden and more often required hospitalization, surgery, and medication for their disease, data from a U.S. registry showed.

In the analysis of nearly 900 Crohn's disease patients enrolled in the CorEvitas inflammatory bowel disease (IBD) registry in recent years, 17.7% had a history of PF, and these patients tended to be diagnosed earlier than those without PF (28 vs 35 years) and have a longer disease duration (median 16.5 vs 12.3 years, respectively), reported Ryan Stidham, MD, of the University of Michigan in Ann Arbor, and colleagues.

PF can significantly affect a patient's quality of life, and management and prevention of this manifestation of Crohn's disease can be challenging, explained Stidham and co-authors, writing in .

Medical treatment can include tumor necrosis factor (TNF) inhibitors or other biologic therapy. "However, even with optimal management, the best healing rates for [PF] are approximately 50%," they wrote. "As a result, surgery is often required, which may include seton placement or, in some cases, intestinal diversion with an ostomy."

In their study, the researchers found that the PF group were more likely to have a history of hospitalization (76% vs 58%), IBD-related emergency department visits (68% vs 56%), or surgery for IBD (59% vs 28%) compared to those without PF.

They also found that Crohn's disease patients with PF had lower remission rates -- as defined by Harvey Bradshaw Index (HBI) scores of 0 to 4 -- compared to those without PF (56.8% vs 69.6%), and more likely to have moderate or severe disease activity.

Also, PF patients were more likely to have received biologic therapy (88% vs 69%) or immunosuppressants (52% vs 31%) for their Crohn's disease.

"This high proportion of biologic use is not surprising, and although we did not investigate prescribing behavior, the finding suggests that practitioners may be prescribing biologics for patients with PF and that patients are readily using such drugs in greater proportions than in the past decade," noted Stidham and colleagues. "Further research is warranted to determine which interventions or therapies, if any, can prevent or reduce the incidence of PF in patients with [Crohn's disease], to help patients avoid more intensive therapies and improve their health outcomes."

Reached for comment, Sandra El-Hachem, MD, of the Allegheny Center for Digestive Health in Pittsburgh, told 番茄社区app that "patients with penetrating perianal Crohn's disease are considered to have a more severe natural history."

"This is why in clinical practice we treat this patient population with a more aggressive approach and use biologic therapy, especially anti-TNF therapy, more frequently and very early in the disease process," said El-Hachem, who was not involved in this study.

has shown that in patients with PF, 28% develop them within 6 months of their Crohn's disease diagnosis and 79% develop them within 10 years of a diagnosis. Currently, the absence of real-world patient data has limited strategies for prevention and treatment, the researchers noted.

For their study, Stidham and colleagues looked at 878 Crohn's disease patients enrolled in the CorEvitas IBD registry from May 2017 to March 2020. Of those, 155 patients had a current or previous PF and 723 had none. Patients whose initial Crohn's diagnosis was later changed were excluded from the analysis.

Overall, patients were an average age of 47 years, 42% were male, 87% were white, and nearly three-fourths were privately insured. Just over a third were current or past smokers and 60% were overweight or obese. No between-group differences were seen with regard to disease location or duration of current IBD therapy.

The PF group was slightly younger (mean 44 vs 47 years in the non-PF group), more likely to be male (56% vs 39%), had a slightly higher mean HBI score (4.4 vs 3.8), and had more eye involvement (6% vs 2%).

For ongoing therapies, more patients in the PF group were receiving biologics or Janus kinase (JAK) inhibitors (76.8% vs 61.3%) overall, TNF inhibitors (48.4% vs 38.0%), and immunosuppressants (22.6% vs 14.7%), and fewer were receiving 5-aminosalicylic acid (11% vs 21%).

The authors acknowledged limitations to the data, including that geographical differences may apply as the registry included gastroenterologists from 20 states. There also remains a possibility for misclassification due to patients' recall bias.

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