In this study, 30.0% and 35.0% of patients achieved clinical fistula remission and response at week 16/20 after UST initiation, respectively; 37.5% (3/8) achieved deep radiological fistula healing according to post-treatment MRI. Our clinical and radiological results verified an acceptable short-term efficacy of UST on perianal fistulizing CD.
Infliximab was the first proved effective biologics in promoting and maintaining CD-related fistula closure, supported by high-quality randomized controlled trials (RCTs) with the primary endpoint as fistula closure5,10. According to a multicenter, double-blind RCT conducted by Daniel and his colleagues5, 40% of patients had complete fistula response at week 54 after scheduled infliximab administration. Adalimumab is effective in treating fistulizing CD with lower grade evidence though11. A majority of studies, prospective or retrospective, reported 30–50% of patients achieved clinical fistula remission after long-term anti-TNF therapies5,10,12. Our results showed that a relatively lower percentage (23%) of patients presented fistula closure. Given that this study focused solely on the short-term efficacy of UST, favorable long-term outcomes might be expected.
UST is the second-line biologics recommended for perianal fistulizing CD. A post hoc analysis of UNITI-1/UNITI-2 reported that 24.7% of patients achieved fistula closure at week 8 and that 80% of patients achieved clinical fistula response at week 44 after UST treatment13. A small sample-size retrospective study in Spain revealed that 61% (11/18) of patients demonstrated improvement in perianal fistula at 10 months after scheduled UST. A BioLAP study14, including 207 perianal CD patients, was a retrospective trial with the largest sample size reported to date. It showed that therapeutic success reached in 38.5% of patients treated by UST. A prospective observational study in Netherlands reported 35.7% (10/28) of patients achieved clinical fistula remission at week 24 after UST initiation15. However, unlike anti-TNF agents, there still lacks RCTs with fistula closure as the primary endpoint to evaluate the efficacy of UST on perianal fistula.
UST was first approved for the treatment of CD in 2016 in America, but in 2020 in China. The efficacy of UST on CD has been rarely reported in China, and never on perianal fistulizing CD. To our knowledge, this is the first real-world study in China reporting the effectiveness of UST on perianal fistulizing CD. The clinical fistula remission rate was 30.0%, approximating those reported previously16. Further, MRI scans showed a deep radiological fistula healing rate of 15.6%, lower than the clinical fistula remission rate. It indicates that radiological fistula healing lags behind the clinical fistula closure, calling for a greater effort to realize the former.
Pelvis MRI is a pivotal tool for perianal fistula diagnosis, classification, severity evaluation, and disease monitoring. Radiological fistula healing continues after clinical fistula closure, for internal tracks may persist despite the closure of external opening, thus leading to a higher rate of relapse17. Patients who achieve radiological fistula remission may maintain fistula resolution, regardless of continuation or stop of anti-TNF therapy18. In this study, all the eligible patients enrolled had a precise diagnosis and classification of perianal fistula based on MRI scans. Besides, 38.1% (8/21) of patients underwent MRI scans in post-therapy follow-up. Radiological fistula healing rate was 37.5%, indicating an ideal efficacy of UST on complete fistula closure. Follow-up imaging can assist disease monitoring and therapeutic management.
Perianal fistulizing CD exerts profound effects on patient’s psychosocial state and daily life19. Limited data have been obtained regarding the quality of life affected by perianal fistula to date. PDAI is widely used to measure CD-associated perianal disease activity. It is neither specific to perianal fistula and nor patient-centered 20. CAF-QoL is the first disease-specific and patients-reported outcomes index in clinical practice, involving factors such as burden of symptoms and treatment, and negative impact on quality of life21. In this study, we combined PDAI and CAF-QoL to evaluate the impact of perianal fistula on CD patients. Favorable changes in both PDAI and CAF-QoL were found after UST therapy.
It has been reported that IFX concentration of 12µg/ml was associated with fistula remission. Optimizing biologics correlates to a higher response rate in perianal fistulizing CD patients22. Nevertheless, no studies have proposed the cut-off UST trough level associated with fistula healing yet. Sands et al. drew a conclusion that perianal fistula resolution was not associated with a higher UST serum concentration23. In contrast, one observational study noted that 50% of patients with UST escalation into q4w or q6w administration intervals achieved clinical response in perianal disease24. In this study, we did manifest exposure-effect relationship between clinical fistula remission and UST trough level. The cut-off value of UST we reported was 2.6µg/ml, much higher than 1.12 µg/ml, a cut-off value of UST associated with clinical remission (defined as CDAI < 150) we reported previously9. Undoubtedly, more high-quality studies are needed to further testify the relationship of UST escalation and fistula outcomes.
There are limitations in this study. First, the evidence from this retrospective study should be further validated. Moreover, it was a single-center study with a relatively small sample size and a short-term follow-up; the long-term efficacy of UST on perianal fistula was missing. The strengths of this study include strict definitions, radiological evaluation combined with clinical assessment, and emphasis on quality of life. Not covered by the insurance system, the cost of UST is high in China, and a small number of Chinese patients can afford UST. Most of Chinese patients come to our center to seek UST treatment, enabling us to release these data in a real-world setting for the first time.