Therapeutic Optimization in Crohn's Disease - Episode 5
Stephen B. Hanauer, MD: When we are approaching the treatment of someone with mild to moderate Crohn’s disease, we still have to take a holistic approach to the patient, understand what their primary symptoms are, and observe them for any evidence of progression. By a “low-risk patient,” we mean individuals who are less likely to progress to the transmural complications of stricture and fistula. These are usually individuals with short segments of disease, and what I consider to be superficial inflammation. They do not have the deep ulcers, but may have aphthous ulcers, or cold sores, or very mild local inflammation. These patients can respond to nonsystemic steroids, such as budesonide. Some of these patients actually respond to mesalamine. Often, these patients will respond to non—anti-inflammatory therapies, just symptomatic treatment such as antidiarrheals or antispasmodic treatment. Because these individuals have such a low risk of progression, we’ve also found that these are the patients who respond to placebo in controlled trials.
The goals for treatment for Crohn’s disease don’t really depend on the risk. The goals are first and foremost to control symptoms, which include patients’ quality of life. When we treat beyond the symptoms to mucosal healing, that’s where we actually see longer term impacts on patients, resulting in less surgeries, less need for hospitalizations, and long-term improvement in quality of life.
Bruce E. Sands, MD: To treat patients with low-risk disease, we have a dilemma. We want to treat the disease adequately, but, on the other hand, we don’t want to overtreat the disease. Truthfully, we don’t have a lot of different agents in our armamentarium that are perfectly suited for low-risk disease. The analogy in ulcerative colitis would be something like the 5-aminosalicylates, which are good for about a third of patients with mild to moderate ulcerative colitis. But we don’t have the equivalent treatment in Crohn’s disease. Therefore, generally what’s recommended is if someone has low-risk disease, we might initially treat with budesonide controlled ileal release. If it’s ileal or right colonic inflammation, we may follow that up with azathioprine or mercaptopurine to sustain the response or remission. We might treat with prednisone if the disease is more extensive in nature, but we’re always following up and trying to ascertain whether or not the patient actually did respond clinically and whether or not the patient had healing of mucosa.
William J. Sandborn, MD: I’m often asked what to do if someone is in clinical remission. Do you continue therapy? Should you deescalate therapy? My feeling is that the drugs we use in Crohn’s disease, whether they’re biologic drugs, steroids, or immune suppressive drugs, have all been shown to not have a durable effect after the treatments are stopped. They’ll be effective for inducing and then maintaining remission, but if you withdraw therapy, you risk relapse. So, my general approach, once I’ve identified a nonsteroid drug that’s effective in the patient, is to continue that drug for the long term, assuming that the patient can tolerate it.
Another good question is when to step up treatment. Basically, my thinking about this is that I want the patient to be in both clinical remission and endoscopic or colonoscopy remission. So, if I have a patient who has persistent symptoms, I will evaluate them with some kind of objective measure. Sometimes, it could be a biomarker like fecal calprotectin or CRP (C-reactive protein). More often it’s going to be colonoscopy, and if at colonoscopy I see significant ulceration that would be compatible with the patient’s symptoms, then that’s going to lead me to step up therapy. And then, it depends on what treatment they’re on. If they’re on steroids, I’ll probably go to some kind of biologic, usually in combination with immune suppressive agents.
Transcript edited for clarity.