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P594 Utilisation of anti-TNF agents in phlegmonous Crohn’s disease: an Australian tertiary referral centre experience

Chiu, L.(1);Digby-Bell, J.(2);Seah, J.(1,3);Melton, S.(1,4);Taylor, K.(1,2);Sparrow, M.(1,2);

(1)Monash University, Faculty of Medicine- Nursing and Health Sciences, Melbourne, Australia;(2)Alfred Health, Department of Gastroenterology, Melbourne, Australia;(3)Alfred Health, Department of Radiology, Melbourne, Australia;(4)Alfred Health, Nutrition Department, Melbourne, Australia

Background

Phlegmonous Crohn’s disease (CD) is a complication of penetrating disease where traditional management was surgical. There are a paucity of studies evaluating its medical management. The aim of our single-centre, retrospective case series was to evaluate the efficacy and safety of anti-TNF therapy in managing phlegmonous CD.

Methods

Cases were identified through searching patient records for CT, MRI and intestinal ultrasound reports containing the words “Crohn’s” and “phlegmon”. Patients were included if found to have CD-related phlegmon subsequently started on anti-TNF. Patients were excluded if they were already on an anti-TNF at diagnosis, or underwent surgery prior to starting anti-TNF. Electronic review of patient records was undertaken to determine demographics, current medication, length of disease and surgery.

Results

Of the 66 cases identified, 11 fulfilled inclusion criteria. 2 cases required surgery at 38 and 197 days post-phlegmon diagnosis, both of which had earlier ceased anti-TNF due to failed trial and severe depression respectively. 4 patients discontinued anti-TNF during follow up: 1 experienced severe anaphylaxis, 1 failed anti-TNF trial, and 2 ceased due to personal preference (severe depression, concern about adverse effects). 8 of 10 had complete resolution of the phlegmon with 1 patient awaiting imaging 6 months post-phlegmon diagnosis.

Table 1: Demographics

CharacteristicNo. of patients
Age at time of phlegmon, years (median, range)30, 20-55
Sex 
Male8
Montreal classification 
AgeA2: 10 , A3: 1
LocationL1: 5, L2: 1, L3: 4
BehaviourB2: 3, B3: 9
Perianal disease2
Smoking status
Current1
Ex1
Never9
Medications at time of phlegmon diagnosis 
None2
Steroids3
Immunomodulator therapy3
5-ASA2
Ustekinumab1

Table 2: Treatment and outcomes (n=11 unless otherwise stated)

OutcomeResult
Length time from CD diagnosis to phlegmon, years (median, range)1, 0-18
Length time from phlegmon diagnosis to starting anti-TNF, months (median, range)1, 0-19
Length time of phlegmon resolution, months (median range), n=102.5, 0-18
Anti-TNF (patients) 
Infliximab9
Adalimumab2
Immunomodulator (patients), n=10 
Azathioprine5
Methotrexate2
Mercaptopurine3
Antibiotics (patients)7
Steroids (patients)2
Exclusive enteral nutrition (patients)6
CRP, n=9 
Pre-treatment (at time of phlegmon)19.6, 1-160
Post-treatment (2-5 months post-phlegmon)3, 1-295
Surgery (patients)2
Surgery, days from phlegmon to surgery (median, range), n=2117.5, 38-197
Length of outpatient follow-up, months (median, range)20, 3-74

Conclusion

9 of 11 of our patient cohort avoided surgery after starting anti-TNF therapy for phlegmonous CD, out to a median follow up of 20 months. Our findings suggest anti-TNFs are generally well tolerated, and early commencement may be effective in preventing surgical intervention.

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