title: Use of Endoscopic Ultrasound to Guide Adalimumab Treatment in Perianal Crohn's Disease Results in Faster Fistula Healing.
abstract: BACKGROUND
  Perianal disease is a manifestation of Crohn's disease (CD) that has poor long-term treatment outcomes. The aim was to determine if rectal endoscopic ultrasound (EUS)-guided therapy with adalimumab (ADA) can improve outcomes for patients with perianal fistulizing CD.
  
  
  METHODS
  This is a randomized prospective study comparing serial EUS guidance of fistula treatment versus standard of care in fistulizing perianal CD. At enrollment, all patients underwent a rectal EUS and an EUA with seton placement and/or I&D. Treatment was maximized with immunomodulators, antibiotics, and ADA induction. Surgical interventions were determined by the surgeon's discretion in the control group and assisted by every 12th week EUS in the intervention group. Primary and secondary endpoints where complete drainage cessation at week 48 was fistula status per EUS, respectively.
  
  
  RESULTS
  Twenty patients were enrolled: 11 control and 9 EUS guidance. At 24 weeks, 7/9 (78%) in EUS group and 3/11 (27%) in control group had drainage cessation (P = 0.04). This significant difference was lost at week 48 (P = 0.44). Three patients in the EUS and 1 in the control group had additional surgical intervention. Those in the EUS group had more rapid escalation of ADA dosing (P = 0.003). There was no difference in the change in PDAI at week 48 versus baseline (P = 0.81).
  
  
  CONCLUSIONS
  Rectal EUS-guided ADA therapy for CD perianal fistulas showed an initial benefit at 24 weeks, which was lost at week 48. This is likely due to small sample size and higher fistula closure in the controls. However, the faster rate of fistula resolution is a clinically significant finding.
authors.affiliation: *Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee; †Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee; ‡Department of Colorectal Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; and §Section of Colon and Rectal Surgery, Washington University School of Medicine, St. Louis, Missouri.
authors.forename: Dawn M
authors.initials: DM
authors.lastname: Wiese
authors.forename: Dawn
authors.initials: D
authors.lastname: Beaulieu
authors.forename: James C
authors.initials: JC
authors.lastname: Slaughter
authors.forename: Sara
authors.initials: S
authors.lastname: Horst
authors.forename: Julie
authors.initials: J
authors.lastname: Wagnon
authors.forename: Caroline
authors.initials: C
authors.lastname: Duley
authors.forename: Kim
authors.initials: K
authors.lastname: Annis
authors.forename: Anne
authors.initials: A
authors.lastname: Nohl
authors.forename: Alan
authors.initials: A
authors.lastname: Herline
authors.forename: Roberta
authors.initials: R
authors.lastname: Muldoon
authors.forename: Tim
authors.initials: T
authors.lastname: Geiger
authors.forename: Paul E
authors.initials: PE
authors.lastname: Wise
authors.forename: David A
authors.initials: DA
authors.lastname: Schwartz
mesh_terms: D000068879:Adalimumab / Q000627:therapeutic use*; D000328:Adult; D003424:Crohn Disease / Q000150:complications / Q000000981:diagnostic imaging / Q000188:drug therapy*; D019160:Endosonography / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D005765:Gastrointestinal Agents / Q000627:therapeutic use; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012003:Rectal Fistula / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000209:etiology; D016896:Treatment Outcome; D014945:Wound Healing / Q000187:drug effects*
chemical_list: D005765:Gastrointestinal Agents; D000068879:Adalimumab