Improved Crohn’s disease treatments thanks to research

By Randy Longman, MD, as told to Marijki Vroomen-Durning, RN

I’ve been working with patients with inflammatory bowel disease (IBD), which includes Crohn’s disease, for about 15 years now. Treating patients with chronic diseases such as Crohn’s disease can be challenging, but also very beneficial. As their physician, I have the unique opportunity to develop long-term relationships with them. I am there in difficult times to provide medical assistance, care and support.

It’s also an exciting time to be in the field of Crohn’s disease treatment because of the ongoing research and new treatment options that can be life-changing for my patients. With so much going on, I don’t want my patients to lose hope because we don’t know what’s around the corner. There are so many medicines and combinations of treatments that sometimes the following medicine can be the right medicine for you.

Diagnosis and treatment have improved over the years

The treatment of Crohn’s disease has changed significantly since I started taking it. Early on, we only had oral medications, such as steroids, or corticosteroids, to give our patients. These medications can certainly be helpful in some situations. They reduce inflammation in the gut, especially during exacerbations or flare-ups. But these medications can also have dangerous side effects. For example, long-term steroid treatment can cause cataracts and weak bones, and can put patients at greater risk for infection. So we don’t want patients to take these drugs too often or for long periods of time.

Immunomodulators were our other option. They are also good medicines, and they help many patients. The most common medications used to treat Crohn’s disease include:

• Azathioprine (Azasan, Imuran)
• Mercaptopurine (Purinethol, Purixan)
• methotrexate (Trexall)

These medications reduce inflammation by adjusting how your immune system reacts and reducing symptoms. But it can also have serious side effects, such as nausea, fever, and fatigue, so some people can’t take it.

But now, there is more hope. Thanks to research and development, the treatment of Crohn’s disease has surpassed steroids and immunomodulating drugs. Now, we have biological therapies that we offer to patients with Crohn’s disease. These are drugs that target specific inflammatory molecules in the body. In my opinion, they have changed the natural history of this disease.

In 1998, the FDA approved the alpha-targeting anti-factor drug infliximab for the treatment of Crohn’s disease. Over the past 10 to 15 years, we’ve had many other anti-TNF alpha-targeting drugs, as well as others that target specific enzymes and their pathways. These new drugs provide new options for patients who have not been successful with conventional treatments.

But Crohn’s disease treatments don’t stop there

Historically, we’ve treated patients with Crohn’s disease by giving them one treatment at a time, adjusting or changing the medication if they don’t respond well. But we’ve learned a lot about combining medications to make them work better. This gives us another way to help our patients.

Testing has also improved. We can now see how well a patient is responding to treatment, not only through symptom relief, but we can now perform blood tests to monitor therapeutic drugs (TDM). Measuring blood drug levels allows us to effectively monitor our patients’ progress, and to make the most of their care.

We have also come up with new diagnostic techniques, including genetic and molecular blood markers. These signs tell us about the type of IBD and the subtypes of Crohn’s disease that the patient has. This knowledge helps us design personalized treatments for patients.

Recognition is coming earlier

The earlier patients with Crohn’s disease are treated, the better, and early recognition and diagnosis play a huge role in this. Organizations like the Crohn’s and Colitis Foundation and others have done tremendous work to raise awareness of inflammatory bowel disease, including Crohn’s disease. Communication with them encourages people to talk about symptoms even if they are embarrassing or difficult to talk about. Allowing and encouraging people to talk about symptoms such as abdominal pain, diarrhea or even rectal bleeding means they may be diagnosed earlier if they have IBD.

A team approach improves Crohn’s disease care

Other contributions to the holistic healthcare approach to Crohn’s disease have also made a difference in how well treatment works.

Clearly, the primary focus should be to determine appropriate medications to help manage the intestinal or systemic inflammation from Crohn’s disease. But even after the inflammation is under control, there can still be uncomfortable intestinal symptoms such as gas, bloating, and diarrhea.

Malnutrition in Crohn’s disease is also a real problem. Because of enteritis, nutrients, especially vitamins, are not easily absorbed. Children with Crohn’s disease can also experience developmental delays.

One of the ways we deal with this in our center is by having a dietitian who focuses on IBD. Having a dietitian familiar with the nutritional issues associated with IBD can make a huge difference to a patient’s well-being.

Healthcare professionals to address the psychosocial issues related to living with Crohn’s disease are also essential. These problems can affect anyone of any age, but some groups may be at higher risk. Symptoms of Crohn’s disease often begin in late adolescence and early adulthood. This can be a very stressful time for most teens in high school or college adjusting to life with a chronic illness, so sensitivity and support are critical. In our practice, and in many IBD centers, the social worker is often on the team. As a result, they can examine the challenges our patients may face and provide resources and support.

It is also important to realize that even for adults, this disease can be very stressful. There are not only medical problems, but also social and occupational problems, and treatment comes with a financial burden. So even if you have insurance, even if you have good insurance, there are always major medical and financial issues if you have a chronic illness.

I look forward

I think there are still many unmet needs when working with people with Crohn’s disease. First, a lot of research looks at early recognition of the disease, especially among people with a family history of it. Another focal point is figuring out which medication to choose for which patient, based on algorithms, how severe the disease is at the time, and other things like medication side effects.

We also need to consider areas of active research into complications related to Crohn’s disease. For example, it can cause a fistula, which is an abnormal opening in the colon, and this can be very aggressive. Crohn’s disease can also cause fibrosis, thickening, and scarring of the tissues in the colon, which can lead to strictures or blockages. This major complication of Crohn’s disease can lead to the need for surgery.

We do not yet have drugs that directly target fibrosis or restriction. But I do anticipate that over the next five to 10 years, we’ll have drugs to specifically target this and reduce the drastic burden that comes with Crohn’s disease.