Early use of immunomodulators and biologic agents in paediatric Crohn’s disease reduces the risk of perianal disease by about 60% within two years, a US study shows

A retrospective analysis of records for 2214 young people with CD under the age of 24 without perianal disease at baseline found that almost 20% developed perianal fistulising complications within 24 months.

However for the 56% of patients who started on steroid sparing therapy (SST) with immunomodulators such as thiopurine, methotrexate and/or anti–TNF α medications the risk of developing perianal complication was reduced by a 59% compared with no SST use (hazard ratio 0.41; 95%CI, 0.33-0.52; P < 0.001) .

The two-year rate of remaining free from perianal fistulising complications  was 73.1% for patients who did not use SST vs 87.3% for patients who initiated SST

And in those who did develop perianal disease the use of SST was associated with a 55% reduced risk of surgery compared to nonusers. Of the 40 patients who underwent ostomy, seven had initiated SST, and 33 had not.

Published in JAMA Network Open, the study showed that the risk reductions for perianal disease were 52% for use of immunomodulators alone, 47% for use of an anti-TNFα alone, and an 83% reduction with combination therapy, compared with no SST use.

The study authors said their findings showed that perianal fistulising complications are common in children with Crohn’s disease but may be preventable with therapies that should be used early in the disease.

“These are important findings because perianal fistulising complications can be devastating, with long-lasting major negative consequences on quality of life,” they wrote.

“They can cause pain, feculent drainage, faecal incontinence, and dyspareunia and are often associated with negative body image and depression. Perianal fistulizing complications are difficult to treat; they often require invasive surgical procedures but still commonly reoccur,” said the authors from the Division of Pediatric Gastroenterology, University of Michigan, Ann Arbor.

An accompanying commentary by Professor Sunanda Kane of the Mayo Clinic, Rochester, said the findings “should be compelling to parents and patients. The benefits of avoiding surgery, pain, and physiologic dysfunction cannot be understated.”

She said the clinical benefits or preventing perianal fistulas should outweigh concerns over adverse effects of SST, and the use of biologics would be cost saving in the longer term because they prevent emergency department visits, hospitalisations, and surgical procedures.