Local Injection of Antibody Tumour Necrotising Factor TNF

The TNF blocker infliximab has been proven to be safe and effective in the treatment of both luminal and fistulising Crohn's disease, particularly when used as maintenance therapy with infusions at fixed intervals [50, 51]. This treatment is described in the medical treatment chapter. Further advantages of infliximab therapy include the steroid-sparing effect, the decrease in concomitant anti-inflammatory medication use (mesalazine, sulfadiazine), as well as the reduction in hospitalisations and surgeries and the improved quality of life. Some recent pilot studies have reported the potential benefit of local injection of infliximab for the treatment of perianal fistulae in Crohn's disease [52-54]. It seems that this method of administration minimises the adverse effects associated with the systemic use of infliximab [55].

The treatment consists of a three-step procedure:

1. Removal of the seton.

2. Injection of anaesthetic (5 ml of lidocaine 1% mixed with 3 ml of 8.4% bicarbonate solution).

3. Injection of infliximab (20 mg diluted in 10 ml of physiologic solution) along the fistula tract and around both orifices.

These injections are repeated every 4 weeks until complete remission is reached and maintained. Lichtiger reported nine patients with mild to moderate perianal disease refractory to antibiotics, 6-mer-captopurine or systemic infliximab. They were subsequently treated with circumferential and intrafistu-lae injections of infliximab at 1,2 and 4 weeks. Within 4 weeks, complete healing of fistulae was observed in 4/9 patients and a partial response in 3/9 patients, whereas no response was observed in the remaining 2 patients [53]. Poggioli et al. [54] modified the technique by injecting infliximab at the internal and external orifices and along the fistula tract in order to allow the closure of the entire tract. Fifteen patients in whom sepsis was not manageable using surgical or medical therapy, were included in the study. Efficacy was obtained in ten of fifteen patients after 3 to 12 injections and no major adverse effects were reported. Local infliximab injection seems to be effective, safe and feasible for the treatment of selected cases of perianal Crohn's disease. This treatment can thus represent an alternative to either medical or surgical therapies.

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