Efficacy of anti-TNFs for internal fistulae in CD

Efficacy of anti-TNFs for internal fistulae in CD

April 21, 2020

Issue 08

Clinical Question

Are anti-TNF agents effective in healing internal fistulae?

Editor’s Bottom Line

Anti-TNF therapy can be effective for closing internal fistulas in patients with Crohn’s disease (CD), but some patients appear to be more responsive than others. An individualized approach should be taken.


Bougen G, Huguet A, Amiot A, et al. Efficacy and Safety of Tumor Necrosis Factor Antagonists in Treatment of Internal Fistulizing Crohn’s Disease. Clin Gastroenterol Hepatol. 2020;18(3):628–36; https://doi.org/10.1016/j.cgh.2019.05.027


Studies of anti-tumor necrosis factor (TNF) drugs for treatment of fistulizing CD have focused mainly on perianal fistulae. To better understand the impact on internal fistulae, French researchers retrospectively analyzed data from a GETAID clinical trial, which was performed between 2000 and 2017. They analyzed 156 CD patients with internal fistula who had received an anti-TNF agent. Eighty-three participants were male and the median disease duration was 4.9 years.

Over 61% of participants had a complex internal fistula and 41.6% had a related abscess. Roughly half had a simple fistula tract, 43% had an enteroenteric fistula, 4% had an enterovesical fistula and one patient had an enterouterine fistula. Abscesses were a median 25 mm in size. Seventeen per cent of those with an abscess underwent percutaneous drainage prior to anti-TNF treatment. Seventy-five percent of patients received infliximab, while the remainder received adalimumab.

Results showed that 41% of patients experienced fistula healing within a median of 13.2 months (Range: 6–26 months). The likelihood of fistula healing one, three and five years after anti-TNF treatment initiation was 15.4%, 32.3%, and 43.9%, respectively. A median 3.5 years after treatment initiation, 43.6% of patients had undergone major abdominal surgery. Independent predictors of surgery at treatment outset included C-reactive protein >18 mg/L, albumin <36 g/L, the presence of an abscess, and the presence of a stricture. A stricture at the time of fistula diagnosis, haemoglobin <125 g/L, albumin <36 g/L and female sex were all significantly associated with lower likelihood of fistula healing in multivariate analyses. Abscess size or need for percutaneous drainage was not associated with the likelihood of fistula healing.


Study Design: Retrospective analysis
Funding: Not disclosed
Allocation: Not applicable
Setting: Multicenter
Level of Evidence: 2b (Oxford Levels of Evidence)