Clinical outcome in complex perianal Crohn�??s disease after using infliximab and azathioprine: case report

K.Pavlovska

Abstract

We present a case of a 25 year old male patient, with severe active Crohn’s disease, treated with corticosteroids and mesalazine. Due to worsening of the disease, he was referred to the University Clinic of Gastro entero hepatology with anal, scrotal fistula and anal perineum fissure. His condition required total colectomy, terminal ileostomy and excision of  granuloma, fistulotomy and fistula drainage. Postoperatively, he was administered mesalazine, corticosteroids, antibiotics and azathioprine. He did not respond and anti-TNFα was started. During a period of 14 weeks, he received 4 cyclеs of infliximab (5 mg/kg) in combination with azathioprine (100 mg). Despite the combination therapy, he failed to respond and his perianal disease worsened. The patient was a primary non-responder, infliximab was stopped after the end of the 4th cycle. He continued taking azathioprine for 2 years, since no other biologic agent was available. Remission was achieved. This long-term administration resulted in fistulas healing and anal fissure closure. The patient continued being treated with azathioprine for maintaining of the remission with regular laboratory control and close monitoring of possible adverse events. The limited alternative biological therapies, i.e., no possibility to switch to another biologic agent with other mechanisms of action, and no therapeutic concentration monitoring, time to achieve remission for this patient was extended and his quality of life was significantly declined. It is important to point out that in developing countries, biological agents are expensive therapeutic options and are not available in the public health program. This results in poor clinical outcome of the disease.