Clinical Practice Guideline for the Medical Management of Perianal Fistulizing Crohn's Disease

The Toronto Consensus

A. Hillary Steinhart, Remo Panaccione, Laura Targownik, Brian Bressler, Reena Khanna, John K. Marshall, Waqqas Afif, Charles N. Bernstein, Alain Bitton, Mark Borgaonkar, Usha Chauhan, Brendan Halloran, Jennifer Jones, Erin Kennedy, Grigorios I. Leontiadis, Edward Vincent Loftus, Jr, Jonathan Meddings, Paul Moayyedi, Sanjay Murthy, Sophie Plamondon & 4 others Greg Rosenfeld, David Schwartz, Cynthia H. Seow, Chadwick Williams

Research output: Contribution to journalArticle

2 Citations (Scopus)

Abstract

Background: Fistulas occur in about 25% of patients with Crohn's disease (CD) and can be difficult to treat. The aim of this consensus was to provide guidance for the management of patients with perianal fistulizing CD. Methods: A systematic literature search identified studies on the management of fistulizing CD. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. Statements were developed through an iterative online platform using a modified Delphi process, then finalized, and voted on by a group of specialists. Results: The quality of evidence for treatment of fistulizing CD was generally of very low quality, and because of the scarcity of good randomized controlled trials (RCTs), these consensus statements generally provide conditional suggestions (5 of 7 statements). Imaging and surgical consultations were recommended in the initial assessment of patients with active fistulizing CD, particularly those with complicated disease. Antibiotic therapy is useful for initial symptom control. Antitumor necrosis factor (anti-TNF) therapy was recommended to induce symptomatic response, and continued use was suggested to achieve and maintain complete remission. The use of concomitant immunosuppressant therapies may be useful to optimize pharmacokinetic parameters when initiating anti-TNF therapy. When there has been an inadequate symptomatic response to medical management strategies, surgical therapy may provide effective fistula healing for some patients. Conclusions: Optimal management of perianal fistulizing CD requires a collaborative effort between gastroenterologists and surgeons and may include the evidence-based use of existing therapies, as well as surgical assessments and interventions when needed. 10.1093/ibd/izy247_video1izy247.video15978518763001.

Original languageEnglish (US)
Pages (from-to)1-13
Number of pages13
JournalInflammatory Bowel Diseases
Volume25
Issue number1
DOIs
StatePublished - Jan 1 2019

Fingerprint

Practice Guidelines
Crohn Disease
Therapeutics
Fistula
Necrosis
Immunosuppressive Agents
Referral and Consultation
Randomized Controlled Trials
Pharmacokinetics
Anti-Bacterial Agents

ASJC Scopus subject areas

  • Immunology and Allergy
  • Gastroenterology

Cite this

Steinhart, A. H., Panaccione, R., Targownik, L., Bressler, B., Khanna, R., Marshall, J. K., ... Williams, C. (2019). Clinical Practice Guideline for the Medical Management of Perianal Fistulizing Crohn's Disease: The Toronto Consensus. Inflammatory Bowel Diseases, 25(1), 1-13. https://doi.org/10.1093/ibd/izy247

Clinical Practice Guideline for the Medical Management of Perianal Fistulizing Crohn's Disease : The Toronto Consensus. / Steinhart, A. Hillary; Panaccione, Remo; Targownik, Laura; Bressler, Brian; Khanna, Reena; Marshall, John K.; Afif, Waqqas; Bernstein, Charles N.; Bitton, Alain; Borgaonkar, Mark; Chauhan, Usha; Halloran, Brendan; Jones, Jennifer; Kennedy, Erin; Leontiadis, Grigorios I.; Loftus, Jr, Edward Vincent; Meddings, Jonathan; Moayyedi, Paul; Murthy, Sanjay; Plamondon, Sophie; Rosenfeld, Greg; Schwartz, David; Seow, Cynthia H.; Williams, Chadwick.

In: Inflammatory Bowel Diseases, Vol. 25, No. 1, 01.01.2019, p. 1-13.

Research output: Contribution to journalArticle

Steinhart, AH, Panaccione, R, Targownik, L, Bressler, B, Khanna, R, Marshall, JK, Afif, W, Bernstein, CN, Bitton, A, Borgaonkar, M, Chauhan, U, Halloran, B, Jones, J, Kennedy, E, Leontiadis, GI, Loftus, Jr, EV, Meddings, J, Moayyedi, P, Murthy, S, Plamondon, S, Rosenfeld, G, Schwartz, D, Seow, CH & Williams, C 2019, 'Clinical Practice Guideline for the Medical Management of Perianal Fistulizing Crohn's Disease: The Toronto Consensus', Inflammatory Bowel Diseases, vol. 25, no. 1, pp. 1-13. https://doi.org/10.1093/ibd/izy247
Steinhart, A. Hillary ; Panaccione, Remo ; Targownik, Laura ; Bressler, Brian ; Khanna, Reena ; Marshall, John K. ; Afif, Waqqas ; Bernstein, Charles N. ; Bitton, Alain ; Borgaonkar, Mark ; Chauhan, Usha ; Halloran, Brendan ; Jones, Jennifer ; Kennedy, Erin ; Leontiadis, Grigorios I. ; Loftus, Jr, Edward Vincent ; Meddings, Jonathan ; Moayyedi, Paul ; Murthy, Sanjay ; Plamondon, Sophie ; Rosenfeld, Greg ; Schwartz, David ; Seow, Cynthia H. ; Williams, Chadwick. / Clinical Practice Guideline for the Medical Management of Perianal Fistulizing Crohn's Disease : The Toronto Consensus. In: Inflammatory Bowel Diseases. 2019 ; Vol. 25, No. 1. pp. 1-13.
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AU - Bressler, Brian

AU - Khanna, Reena

AU - Marshall, John K.

AU - Afif, Waqqas

AU - Bernstein, Charles N.

AU - Bitton, Alain

AU - Borgaonkar, Mark

AU - Chauhan, Usha

AU - Halloran, Brendan

AU - Jones, Jennifer

AU - Kennedy, Erin

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AU - Loftus, Jr, Edward Vincent

AU - Meddings, Jonathan

AU - Moayyedi, Paul

AU - Murthy, Sanjay

AU - Plamondon, Sophie

AU - Rosenfeld, Greg

AU - Schwartz, David

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N2 - Background: Fistulas occur in about 25% of patients with Crohn's disease (CD) and can be difficult to treat. The aim of this consensus was to provide guidance for the management of patients with perianal fistulizing CD. Methods: A systematic literature search identified studies on the management of fistulizing CD. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. Statements were developed through an iterative online platform using a modified Delphi process, then finalized, and voted on by a group of specialists. Results: The quality of evidence for treatment of fistulizing CD was generally of very low quality, and because of the scarcity of good randomized controlled trials (RCTs), these consensus statements generally provide conditional suggestions (5 of 7 statements). Imaging and surgical consultations were recommended in the initial assessment of patients with active fistulizing CD, particularly those with complicated disease. Antibiotic therapy is useful for initial symptom control. Antitumor necrosis factor (anti-TNF) therapy was recommended to induce symptomatic response, and continued use was suggested to achieve and maintain complete remission. The use of concomitant immunosuppressant therapies may be useful to optimize pharmacokinetic parameters when initiating anti-TNF therapy. When there has been an inadequate symptomatic response to medical management strategies, surgical therapy may provide effective fistula healing for some patients. Conclusions: Optimal management of perianal fistulizing CD requires a collaborative effort between gastroenterologists and surgeons and may include the evidence-based use of existing therapies, as well as surgical assessments and interventions when needed. 10.1093/ibd/izy247_video1izy247.video15978518763001.

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