What is the best medication for managing rectal leakage and odor associated with Crohn's disease?

From the Guidelines

For rectal leakage and odor associated with Crohn's disease, a combination approach including anti-diarrheal medications, odor-controlling agents, and prescription medications to address underlying inflammation is typically most effective, with the most recent guidelines suggesting the use of biologic therapies such as tumor necrosis factor (TNF)-α antagonists or anti-integrin agents for moderate to severe disease 1. When managing rectal leakage and odor in Crohn's disease, it's essential to consider the severity of the disease and the impact on the patient's quality of life. According to the AGA clinical practice guidelines on the medical management of moderate to severe luminal and perianal fistulizing Crohn's disease, patients with severe disease may require more aggressive treatment, including biologic therapies 1. Some key points to consider in managing rectal leakage and odor include:

• Using anti-diarrheal medications like loperamide (Imodium) at 2-4mg after each loose stool (maximum 16mg daily) to reduce leakage by slowing intestinal transit and increasing stool firmness.
• Utilizing odor-controlling agents like bismuth subsalicylate (Pepto-Bismol) at 262mg tablets, 2 tablets up to four times daily, which binds to sulfur compounds that cause odor.
• Prescribing medications that address the underlying Crohn's inflammation, such as mesalamine suppositories (1g daily) for rectal inflammation or hydrocortisone foam (90mg/application) applied rectally once or twice daily for flares.
• Considering antibiotics like metronidazole (500mg three times daily) or ciprofloxacin (500mg twice daily) for 1-2 weeks if bacterial overgrowth is contributing to symptoms.
• Recommending pelvic floor physical therapy to improve sphincter control if weakness is contributing to leakage.
• Emphasizing the importance of maintaining good perianal hygiene, using barrier creams, and wearing absorbent pads to provide additional symptom relief while medications take effect. The ECCO guidelines on therapeutics in Crohn's disease also highlight the importance of medical treatment in managing the disease, including the use of mesalazine, locally active steroids, systemic steroids, thiopurines, methotrexate, and biologic therapies 1. However, the most recent guidelines from 2021 provide more specific recommendations for the management of moderate to severe disease, emphasizing the use of biologic therapies 1.

From the FDA Drug Label

RENFLEXIS is indicated for reducing the number of draining enterocutaneous and rectovaginal fistulas and maintaining fistula closure in adult patients with fistulizing Crohn's disease.

The medication infliximab (IV), also known as RENFLEXIS, is indicated for reducing signs and symptoms of Crohn's disease, including rectal leakage and odor associated with fistulizing Crohn's disease. The recommended dose is 5 mg/kg given as an intravenous induction regimen at 0,2, and 6 weeks, followed by a maintenance regimen of 5 mg/kg every 8 weeks. 2

From the Research

Treatment Options for Crohn's Disease Rectal Leakage and Odor

• The treatment of Crohn's disease rectal leakage and odor typically involves a combination of medications and lifestyle changes.
• According to 3, infliximab is indicated for the treatment of signs and symptoms, and induction and maintenance of remission in patients with moderate to severely active inflammatory Crohn's disease.
• A network meta-analysis 4 found that infliximab, adalimumab, and vedolizumab were superior to placebo for induction of remission in patients with Crohn's disease.
• The combination of infliximab and azathioprine was found to be superior to certolizumab and azathioprine/6-mercaptopurine for maintenance of remission 4.
• A review of Crohn's disease management 5 suggests that early and effective control of inflammation is critical, and that treatment options include steroids, monoclonal antibodies, immunomodulators, combination therapies, or surgery.
• An observational cohort study 6 found that infliximab and adalimumab had similar response characteristics, but that infliximab required concomitant immunomodulator to achieve optimal maintenance of response.
• A guide to diagnosis and management of Crohn's disease 7 recommends that patients with moderate to severe Crohn's disease be treated with corticosteroids, azathioprine, 6-mercaptopurine, or anti-tumor necrosis factor agents such as infliximab or adalimumab.

Medication Options

• Infliximab: a biologic medication that can help reduce inflammation and induce remission in patients with Crohn's disease 3, 4, 6.
• Adalimumab: a biologic medication that can help reduce inflammation and induce remission in patients with Crohn's disease 4, 6.
• Azathioprine: an immunomodulator that can help maintain remission in patients with Crohn's disease 3, 4, 6.
• Corticosteroids: can help reduce inflammation and induce remission in patients with Crohn's disease, but are typically used for short-term treatment due to side effects 5, 7.