Therapeutic Optimization in Crohn's Disease - Episode 19
Stephen B. Hanauer, MD: I’m Dr. Stephen Hanauer, the medical director of the Digestive Health Center at Northwestern Medicine.
The American College of Gastroenterology has recently updated the guidelines for the treatment of Crohn disease in adults. It takes into consideration a number of patient factors as well as the newer medications that have been introduced in the marketplace since the last college guidelines.
One of the issues that we have in the treatment of inflammatory bowel disease is we recognize that NSAIDs [nonsteroidal anti-inflammatory drugs] are commonly used within the population for a variety of different indications, in the setting of inflammatory bowel disease, nonsteroidal anti-inflammatory drugs have actually been found to worsen the disease or exacerbate bleeding and symptoms. Particularly for primary care physicians, we ask that you avoid nonsteroidal anti-inflammatory drugs and look for other ways of treating individual symptoms or problems.
With the recent ACG [American College of Gastroenterology] Guidelines on the treatment of Crohn disease, there has been an evolution of our thinking regarding the role of mesalamine [Canasa] in inflammatory bowel disease. Mesalamine remains a foundational treatment for ulcerative colitis; however, the data in Crohn disease has been more conflicting, and part of the problem is that clinical trials are somewhat older from the late 1990s and early 2000s that don’t incorporate many of our modern endpoints such as mucosal healing. Mesalamine had been thought to be effective in patients with mild to moderate Crohn disease, but the clinical trials really haven’t supported that in conclusion.
There have been some trials that have been positive and some that have been negative. In my personal opinion, I think that mesalamine may be effective for a proportion of patients with mild—meaning superficial—Crohn disease without deep ulcerations. But, again, we do not have the support of clinical trial evidence to put it into our practice guidelines anymore.
When we follow a cohort of patients with Crohn disease from diagnosis over approximately 20 years, at the time of diagnosis, about 80% of patients with Crohn disease have what’s known as luminal disease. They don’t have transmural complications of strictures or fistula. But the evolution over 20 years is the opposite. Only 20% of patients over 20 years do not have the complications of strictures or fistula. So it’s actually the majority of patients with Crohn disease who are more likely to progress.
Fecal calprotectin is a useful biomarker to discriminate between inflammatory disease and noninflammatory disease. In particular, it’s useful in discriminating between inflammatory bowel disease and irritable bowel syndrome.
Currently, we advocate the use of calprotectin in patients with inflammatory bowel disease, with either Crohn disease or ulcerative colitis as a marker for disease activity. The elevation of calprotectin in the stool is associated with mucosal ulcerations—and in the opposite, patients who have normal calprotectin are unlikely to have evidence of mucosal ulceration, particularly in the colon. Calprotectin may not be as useful in the setting of mid-small intestinal Crohn disease as it is in colonic disease, either Crohn disease or ulcerative colitis.
Transcript edited for clarity.