An ideal drug in the management of IBD fistula would treat the disease as well as the fistula; have a rapid onset of action; induce long term remission; be safe, easy to administrate and monitor; and be cost effective. No single drug can achieve all of these goals. The best management strategy is to induce early closure because fistulas lasting more than four to eight weeks are likely to become chronic. Surgery has an important role in the initial treatment of external fistulas. Localized and conservative surgical interventions should be used to drain an abscess and/or to place Seton sutures. Because localized sepsis is often involved in its formation, initiation of drug therapy appears to be appropriate with the use of metronidazole. If closure does not occur within the early weeks, the objective is to avoid the development of complex and destructive fistulas. Once a fistula is chronic, there is debate as to the choice of treatment (Figure 1). The first step is to induce closure of the fistula with a fast-acting drug such as infliximab and maintenance with a long term drug such as AZA or 6-MP, or to start a remitting therapy with AZA or 6-MP followed, if needed, by the use of a drug such as infliximab that promotes closure. The last scenario is what clinical trials have designed so far. Infliximab is the drug of choice in these two scenarios because of its rapid onset of action and high closure rate, and because its effect may last two months or longer after treatment. Repeated courses of infliximab have not been shown to be effective in keeping fistulas closed; the safety of repeated treatment over a one-year period has been shown in patients with active Crohn’s disease. Other fast-acting drugs do not usually maintain their effect long after discontinuation, and chronic or repeated administration of these drugs appears to be of limited long term toler-ability. When a fistula fails to close, adjunctive therapy (antibiotics again, cyclosporine or tacrolimus, perhaps thalidomide) may be considered. At all times, if the active IBD persists, systemic corticosteroids should be avoided or used at the lowest dose. Indeed, steroid use has been associated with a poor prognosis for closure of enterovesical fistulas in one study, and this finding may also apply to other types of fistulas. Although surgery might be considered as the last intervention, this is unfortunately not a definitive cure in patients with IBD. Fast and reliable shopping for drugs – yasmin birth to get safe shopping atmosphere.
Figure 1) Approach to fistulizing disease. AZA Azathioprine; 6 MP 6-Mercaptopurine
Because the course of Crohn’s disease is variable and largely unpredictable, an individualized approach to the treatment of fistulizing disease might be the preferred option based on the clinical situation, the patient’s preference and expectations of quality of life issues, the physician’s experience and local support for using a therapy and consequent cost-benefit compromise.