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Doctors rethink treatment of Crohn's disease

Just came across the wire from THE CANADIAN PRESS:

TORONTO -- Conventional wisdom about the treatment of Crohn's
disease is being turned on its head by a new study.

Traditionally, patients diagnosed with the devastating
inflammatory bowel disease are treated with a "step-up" approach,
a series of drugs given sequentially as their health deteriorates.

First, they get corticosteroids to control symptoms like
abdominal pain and bloody diarrhea. They are then prescribed a
powerful immune-suppressing drug, which prepares them for a third
medication, an antibody that curbs the inflammation at the root of
the disease.

But a group of European and Canadian researchers decided to see
what would happen if they treated newly diagnosed Crohn's patients
immediately with a combination of an immune-suppressing drug,
azathioprine, and an antibody, infliximab, simultaneously. Patients
were only treated with steroids if they had symptoms.

In the study, published in The Lancet, this "step-down"
approach proved to be markedly more effective.

At six months, 60 per cent of patients treated with this method
were in remission, compared with 36 per cent in the step-up group.

After a year, 62 per cent of the step-down patients were in
remission from Crohn's, compared with 42 per cent of the other
group. But the numbers in the latter group rose only because so many
had progressed to taking infliximab.

"The conventional approach was far inferior," said Dr. Brian
Feagan, director of clinical trials at the Robarts Research
Institute of the University of Western Ontario in London, Ont., and
co-author of the study.

He said that treatment methods for Crohn's have developed over
time but have never really been tested in this manner before.
"There's a lot of therapeutic inertia, and physicians tend to
use the most effective drugs only as a last resort," Feagan said.

While the new study is compelling, the researcher said that
instituting the step-down approach in practice will be a tough sell
because drugs such as infliximab (brand name Remicade) are far more
expensive than steroids.

"The third-party payers (insurance providers) would be horrified
if we started treating everyone with biologics like Remicade,"
Feagan said.

But he noted that doing so would pay off because fast and
prolonged remission would reduce other treatment costs, and would
result in better quality of life. While steroids are cheap, they are
toxic in high doses, and Crohn's patients who take them frequently
have a much higher death rate.

Monica Price was diagnosed with Crohn's just before Christmas in
2005, at the age of 50. She suffered from bloating and severe
abdominal pain, and then developed welts on her shins (called
erythema nodosum) that are a telltale sign of Crohn's.

She was prescribed steroids but suffered troublesome side effects
including insomnia, facial puffiness and a voracious appetite that
translated into significant weight gain.

Because she was a participant in a study not the same one whose
results are published now but similar in nature Price began taking
azathioprine (brand name Imuran) and Remicade after only three weeks
on steroids.

"I started feeling better as soon as the infusion began," she
Price has been in remission ever since.
"All my symptoms are gone. It's amazing," she said.
Price gets infusions of the drug once every 10 weeks.

The new research involved 133 patients in Belgium, the
Netherlands and Germany, half of whom were treated with the
traditional step-up approach and half with the step-down approach
over a two-year period.

Dr. Geert D'Haens of the Imelda Gastrointestinal Clinical
Research Centre in Bonheiden, Belgium, and lead author of the study,
called the findings a milestone in the management of Crohn's.
"All classic paradigms for the management of Crohn's disease
need to be questioned," he said.

D'Haens said the findings should also inspire researchers and
clinicians to rethink their treatment of other conditions such as
ulcerative colitis and rheumatoid arthritis that are also treated
with biologics like Remicade.

About 170,000 Canadians suffer from inflammatory bowel disease
which includes two similar but distinct conditions: Crohn's and
ulcerative colitis according to the Crohn's and Colitis Foundation
of Canada.

People are most frequently diagnosed between the ages of 15 and
25, or 45 and 55. These diseases affect the digestive system and
cause the intestinal tissue to become inflamed, form sores and bleed
easily. Many patients also suffer extra-intestinal problems,
including joint, skin and eye problems.

There is no known cure for inflammatory bowel disease. It is
treated with drugs, as well as surgery to remove parts of the bowel.


That is certainly an interesting article. I don't feel that the odds with Remicade treatment are all that great though. Keep in mind that I may have had a severe reaction to remicade that nearly killed me....that aside I think that it's important to try "lesser" drugs, such as asacol, first to see if something that has less scary side effects can be effective in treatment. If I had been presented with Remicade as my first resort upon diagnosis I would have ran out of the office and found a new doctor who was more open-minded. Remicade can have severe side effects and does suppress the immune system to the point that makes it difficult to recover from a common cold. Again, I understand I'm bias but you are meeting the rare 2% (or whatever the low odds are). It is not confirmed that my reaction was due to Remicade but the doctors are unwilling to risk trying it on me again.

I'm still looking for the article that says "We've found the Cure for Crohn's"
I'm all for the step-down approach. With more biologics becoming available, there will be more to switch between if antibodies develop.

Humira is working okay for me, but what if it or Remicade could have prevented all the pain and suffering of the past few years. But like the article says, insurance co.'s will be reluctant to get on board with this.


Senior Member
Yeah, I totally understand the traditional step up approach, so I can't fault the doc's for historically going that way... And, I guess (very pessimistic thinking on my part, admittedly) I would be 'afraid' of going the stepdown route... I mean, if that 1-2 combo failed to knock your IBD into remission, what do you do next? Did they happen to mention what happened to those in the study for whom this new approach failed to work it's magic?
I agree with this top-down approach. I actually feel more comfortable taking Humira, as opposed to something like 5asa or 6mp. Even though they are stronger drugs, I'd rather put something biological in my body as opposed to all chemicals.

Saw the article in the paper here just yesterday...Of course, My folks are all for it as they'd like to see me better sooner (currently on predisone, imuran and pentasa) and the current cocktail is playing havoc with side effects....

But remicade costs are wicked - I carry a 80% co pay so I figured about $500 a month out of pocket....haha....I know it seems like a little for sake of health but it's alot when you have a family of 6 and one income to come up with. It's been stresing me out for sure the last week since my doc brought it up, and b/c I am really wondering about the Imuran issues.

That all said, I would like to see another approach for many sufferers, esp those considered *severe* sooner than playing around with all these meds Like I have done....although a good point is made, that if the strong ones are ineffective, then where do you go? Plus I guess the long tern effects of remicade can be bad too esp if you are dx'd young.

I wonder where the insurance companies will go with it. Mine is good in that I don't have to try everything under the sun before approval, it's just the co pay is still high for our family situation. I guess, in the end, it can be very personal for many, many reasons.


Senior Member
Yeah, like, is it just me... but did those doctors (and the 'subject' patients) think/talk/discuss JUST what would come next if you go this route, and it didn't work? Seems like the $64 question to me. And it didn't work for some, altho .. Wellll, I guess 'fortunately' for those for which it did work.. but for the remaining minority..
So from Predisone to Remicade is the step up, and the reverse order is the step down. I wonder what the success rate is for just plain Remicade.
I was on Remicade when it was first introduced in Canada.
Took it for 7 yrs. Then it just didn't want to work for me no more.
Just like that Now my only option is Humira which as some of you know is making me slowly bald.The million dollar question. Stop taking Humira to save my hair and let my crohns go in a tailspin or continue Humira as it is helping my crohn's stay in remission( but not helping my fistulas at all)I already no the answer.

Bald is Beautiful so they say

Just come up with a dam cure!!!
That stinks, scary to think that there might not be a cure until they can do more genetic processing.

Though you would think that with all the stem cell research they could just cut out the bad parts and replace with stem cell grown parts.