P374 Front loading infliximab dosing regimen improves outcomes in Crohn’s Disease perianal fistulas

Lloyd, A.(1);Wilkinson, A.(2);Aleman Gonzalez, H.(2);Ramachandran, S.(2);Whitehead, E.(2);Pattinson, A.(2);Stamp, K.(2);Turnbull, J.(2);Talbot, A.(2);Sebastian, S.(2);

(1)Hull York Medical School, Department of Gastroenterology, Hull, United Kingdom;(2)Hull University Teaching Hospitals, IBD Unit- Department of Gastroenterology, Hull, United Kingdom;


Higher infliximab maintenance trough levels are found to be associated with higher perianal fistula healing rates in Crohn’s Disease. The relevance of accelerated front loading dosing in perianal fistula has not been determined. This study aimed to establish whether front loading with a higher dose infliximab regime at induction is associated with better fistula outcomes.


Crohn’s Disease patients with perianal fistulas treated with infliximab in a tertiary referral centre IBD unit were included. Patients were categorised as standard or front loading based on induction dose infliximab of 5mg/kg or 10mg/kg. The target for infliximab maintenance trough levels was >10mcg/mL. The primary outcome was the need for reintervention (defined as repeat abscess drainage, seton re-insertion, diverting stoma or proctectomy) at 12 months post initiation of treatment. Secondary outcomes were the proportion of patients having clinical healing, radiologic healing and combined clinical and radiologic healing. Drug levels post induction and post first maintenance were evaluated. The proportion of patients needing dose escalation or de-escalation were also assessed. Chi-squared or Fisher exact tests were used to compare categorical variables and Kaplan-Meier survival curves were plotted for re-intervention free survival.


Seventy-nine patients were included in analysis (Males: Females 36:43, median age with fistula = 31). Seventeen (22%) of patients received a front loading dose of 10mg/kg while sixty-two (79%) patients received the standard dose of 5mg/kg among whom 70% had dose escalation. Need for reintervention was significantly lower in patients who received a front loading dosing schedule compared to the standard dose (2/17 (12%) vs 26/62 (42%), p=0.02) (Figure 1). Higher clinical fistula healing rates were observed with front-loading dosing (82% vs 45%, p=0.008). Radiologic healing in those who had follow up Magnetic Resonance Imaging (MRI)  was not significant between both groups (8/17 (47%) vs 20/62 (32%), p=0.133). Target therapeutic infliximab levels at maintenance was achieved in 14/17 (82% of the patients receiving front loading dosing, while this was achieved in only 2 of the 43 (5%) tested patients with standard dosing. Reintervention requirement rates were higher in those patients with suboptimal maintenance levels (17/44 (39%) vs 2/16 (12.5%), p=0.01). The Kaplan-Meier curves confirm that the front loading dosing regimen does prevent the need for reintervention (p=0.03) (Figure 2). 


Figure 2:


Front loading with higher infliximab dose achieves better fistula healing and reduce the need for reinterventions in Crohn`s disease with perianal fistula.