Early, tight control of Crohn’s disease may have lasting benefits – . Health Blog

The gastrointestinal tract (GI) is a remarkable organ: it is located inside our body, but is in regular contact with the outside world due to our ingestion. It is quite incredible that the immune cells of the GI tract are not activated more regularly by the many foreign products he encounters every day. Only when the GI tract encounters an intruder who could cause disease do the immune cells of the GI tract take action.

That is of course under normal circumstances. In people with Crohn's disease, the normally tolerant immune cells of the GI tract are activated without provocation, and this activation leads to chronic or recurrent – but ultimately uncontrolled – inflammation.

Crohn's Disease: A Foundation

Crohn's disease was first discovered in 1932 by Dr. Burrill B. Crohn and colleagues and is a complex inflammatory disease that results from the misdirected activity of the immune system. It can affect any part of the GI tract from the mouth to the anus, but most commonly the end of the small intestine.

Depending on the exact location of the GI inflammation, Crohn's disease can cause any number of symptoms, including abdominal pain, diarrhea, weight loss, fever, and sometimes blood in the stool.

Treatment options for Crohn's disease have grown dramatically since Dr. Crohn and colleagues first described the condition. The basic principle, however, has remained the same: reducing uncontrolled inflammation. Early treatment approaches included non-specific anti-inflammatory drugs such as corticosteroids, which have many potentially serious side effects outside of the gut.

There are a number of newer therapies available today that are more specific to the immune system and target inflammatory pathways that are known to be active in Crohn's disease. These newer drugs, called biologics, are antibodies that block proteins involved in certain inflammatory pathways relevant to Crohn's disease. However, since we do not fully understand which pathways are involved in which patient, choosing a drug for a particular patient is as much an art as a science.

There is increasing evidence of early, aggressive treatment for Crohn's disease

Early approaches to treating Crohn's disease followed a step-up algorithm in which the newer drugs were only used when the patient was not benefiting from established therapies. This sequential approach – known as tiered therapy – has recently been challenged as studies have repeatedly shown that the newer drugs for Crohn's disease are more effective than the old standards and have preferred side effect profiles. Research also shows that early, aggressive interventions and treatments that target not just symptoms but also objective signs of inflammation (as assessed by blood tests, stool exams, imaging, and endoscopy) lead to better health and quality of life, at least in the term.

The researchers recently published a study in the journal Gastroenterology of the longer-term benefits of treating Crohn's patients to reduce both symptoms and inflammation. Specifically, they analyzed follow-up data from patients who participated in the CALM study – a multicenter study that compared two approaches to treating early, moderate, to severe Crohn's disease. In the first approach, the decision to escalate therapy was based solely on symptoms; In the other approach, the decision was based on both symptoms and objective signs of inflammation (e.g., blood tests or a stool test). This second approach is known as tight control. A closely controlled patient might feel comfortable, but therapy would escalate if there were objective signs of inflammation. The primary endpoint of the original CALM study was healing of the inflamed bowel lining, and the data showed that the strict control approach to treatment was more effective in achieving this goal.

The gastroenterology study took the results of the original CALM study one step further. The researchers looked at how patients who had achieved healing of their intestinal lining were doing a few years later. To this end, researchers looked at the incidence of various adverse outcomes (including the need for surgery and hospitalization for Crohn's disease) in patients in the CALM study since the end of the study.

They found that patients who both felt fine and had shown healing of the intestinal lining (called deep remission) had a significantly reduced risk of Crohn's disease getting worse. Healing of the gut lining without feeling good and feeling good without healing the gut lining were also associated with a lower risk of disease progression compared to patients with active symptoms and inflammation, but to a lesser extent.

The study results may not apply to many patients with Crohn's disease

The latest study reinforces a growing body of evidence in support of a treatment approach that emphasizes early interventions to heal the intestinal lining and resolve symptoms. Can we apply the results to most Crohn's disease patients? Not necessarily.

Enrolled patients had never been treated with a newer biological drug or a drug called an immunomodulator, which affects the functioning of the immune system, prior to enrollment in the CALM study. Immunomodulators have been used to treat inflammatory bowel disease (IBD) since the 1960s and are often one of the first classes of drugs to treat IBD. As a result, these study results may not apply to the many people who have been diagnosed with Crohn's long enough to have been treated with an immunomodulator.

In addition, those who received escalation of therapy were treated with increasingly optimized doses of a single biological, adalimumab (Humira). It remains to be seen whether we would get the same results with patients who have been exposed to one biologic or using a different biologic.

The collaboration between doctor and patient is critical to the successful treatment of Crohn's

In my practice, I regularly encourage the use of highly effective therapies early on in order to achieve strict control. For some, the decision to follow this approach is an easy one. It is more difficult for others to escalate from the idea of ​​escalating therapy, possibly with no symptoms, and targeting something they may not feel. Concerns about side effects and the need for frequent monitoring are of paramount importance with roadblocks.

Working with my patients so they can make medical decisions that are consistent with their values ​​but still be informed by evidence is critical to success, as is a commitment to regularly reconsider and reconsider the approach over time.