Opinion Review
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Apr 14, 2020; 26(14): 1554-1563
Published online Apr 14, 2020. doi: 10.3748/wjg.v26.i14.1554
Optimized timing of using infliximab in perianal fistulizing Crohn's disease
Xue-Liang Sun, Shi-Yi Chen, Shan-Shan Tao, Li-Chao Qiao, Hong-Jin Chen, Bo-Lin Yang
Xue-Liang Sun, Shi-Yi Chen, Shan-Shan Tao, Li-Chao Qiao, Hong-Jin Chen, Bo-Lin Yang, First Clinical Medical College, the Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
Xue-Liang Sun, Department of Colorectal Surgery, Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou 215000, Jiangsu Province, China
Bo-Lin Yang, Department of Colorectal Surgery, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
Author contributions: Sun XL and Yang BL participated in the conceptualization of the paper; all authors drafted the manuscript and made critical revisions, and approved the final version of the article to be published.
Supported by the National Natural Science Foundation of China, No. 81673973; 333 Project of Jiangsu Province, China, No. LGY2019069; Developing Program for High-level Academic Talent in Jiangsu Hospital of TCM, No. y2018rc16; Postgraduate Research and Practice Innovation Program of Jiangsu Province, No. SJCX18_0510; and the Open Projects of the Discipline of Nanjing University of Chinese Medicine supported by Academic Priority discipline of Jiangsu Higher Education Institutions.
Conflict-of-interest statement: The authors declare no conflict of interests.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Bo-Lin Yang, MD, Chief Doctor, Professor, Surgeon, Department of Colorectal Surgery, The Affiliated Hospital of Nanjing University of Chinese Medicine, 155 Hanzhong Road, Nanjing 210029, Jiangsu Province, China. yfy0051@njucm.edu.cn
Received: December 12, 2019
Peer-review started: December 12, 2019
First decision: January 19, 2020
Revised: January 20, 2020
Accepted: March 9, 2020
Article in press: March 9, 2020
Published online: April 14, 2020
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.