Intestinal Fistulas Medication

Updated: Mar 08, 2018
  • Author: David E Stein, MD; Chief Editor: Burt Cagir, MD, FACS  more...
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Medication

Medication Summary

As previously stated, it is not yet clear whether medications such as octreotide (a synthetic substitute of somatostatin that suppresses the release of many gastrointestinal hormones) help to close fistulas. Although contradictory findings on the role of medication in fistula closure have been found, research has shown that octreotide decreases overall fistula output. [32] Immunosuppressive agents used in fistula therapy include azathioprine and infliximab.

Novel drug therapy

A 2015 published report highlighted the potential use for serial intrafistular injections of autologous bone marrow-derived mesenchymal stem cells (MSCs) in patients with refractory Crohn fistulas. [37] As determined by this phase I-II study of a small group of patients, the use of locally injected MSCs was safe and efficacious and further benefited patient outcomes through rescue of previously ineffective treatments. [37] Although not a current standard of care, these results provide intriguing insights into future novel therapies.

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Somatostatin Analogs

Class Summary

These agents inhibit the release of serotonin and the secretion of many hormones involved in GI function.

Octreotide (Sandostatin)

Octreotide is an inhibitory hormone consisting of 2 peptides (14 amino acids and 28 amino acids in length) secreted by hypothalamus and delta cells of the stomach, intestines, and pancreas. It inhibits the release of growth hormone (GH) and thyroid-stimulating hormone (TSH) and suppresses the release of many GI hormones (gastrin, cholecystokinin, secretin, motilin, vasoactive intestinal polypeptide [VIP], glucose-dependent insulinotropic polypeptide [GIP]).

Octreotide results in decreased gastric emptying and reduces smooth muscle contractions and blood flow in the intestines. It is approved for use in treating acromegaly (since it blocks GH release) and symptoms related to carcinoid syndrome and VIPomas.

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Immunosuppressants

Class Summary

These agents inhibit the activity of key factors in the immune system. [38]

Azathioprine (Imuran, Azasan)

Azathioprine is a prodrug that is converted in the body to 6-mercaptopurine (6-MP). A member of a group of medicines called antimetabolites, azathioprine is a chemotherapy medication that inhibits the activity of the immune system, consequently reducing inflammation. Originally developed to treat certain forms of leukemia, the drug has been used to treat some conditions in which the immune system is overly active, such as Crohn disease. Clinical studies of azathioprine therapy have demonstrated a significant improvement in closure rates or improvement of the fistula site compared with placebo.

Infliximab (Remicade)

Infliximab is a monoclonal antibody with murine variable regions that specifically bind human tumor necrosis factor alpha (TNF-alpha), which has important role in promoting inflammation. By blocking the action of TNF-alpha, infliximab reduces signs and symptoms of inflammation. Clinical studies have demonstrated that infliximab significantly improved closure rates of fistulas in patients with Crohn disease and was as effective as maintenance therapy in reducing the number of relapses compared with previous medical treatment therapies.

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