Imuran study

[Miki]

Hello, can somebody interpret this study: http://summaries.cochrane.org/CD000...ne-for-the-treatment-of-active-crohns-disease , especially this sentence:

"Azathioprine and 6-mercaptopurine were found to be no more effective than placebo (fake medicine) for inducing remission in Crohn's disease."

So what does that mean? Active Crohn should NOT be treated with Imuran? I know it's used as maintenance as well (although long-term effects of it's effectiveness aren't convincing at all), but it has been prescribed for active Crohn's as well.

Please enlighten me, thanks.

 

[Catherine]

This is my understanding.

Azathiophrine is not good at getting Crohn's into remission but once in remission it good at keeping patients in remission.

 

[DustyKat]

Catherine is spot on Miki.

This study is confirming that Azathioprine/6MP are not meant as remission inducing but rather as maintenance drugs once remission is achieved.

They are deemed as steroid sparing but not in the respect of achieving remission without steroids, it is meant that once steroids have done their job they will take over and produce long periods of remission. This then reduces the need for steroids to control flares.

Dusty. xxx

 

[Miki]

Thanks for your replys.

I've had 2 gastros give me 2 very different opinions, based on my colonoscopy results.
First one says my Crohn is in remission but that I should be taking Imuran to prevent relapses.
Second one says my Crohn is active and that I should be taking Imuran to treat it, and that Imuran doesn't work as maintenance drug. Basically, he ridiculed the first doctor's opinion.

Regarding my condition: I've been in remission for 5 years after having undergone 5 surgeries in short period of time (due to abscesses and fistulas). I've lost large part of my ileum. I've been on no meds for past 3 years.
My blood tests (including inflammation markers) have been good all these years, and I also feel fine. For the past year and half I've had a severe unexplained anemia (very low iron, ferritin and hemoglobin), and had to take the iron intravenously many times.
Colonoscopy (from month ago) showed no visible sign of active disease, and also barium x-ray showed that everything was fine.
2 ulcerations have been seen on the place of anastomosis by the endoscopist but he thought these weren't significant. Sample was taken from this place and the pathology report shows some "inflammatory infiltrate". Is it normal for ulcerations to always show up something pathologically? My gastroscopy is also clear except for the gastritis and also some scarce inflammatory infiltrate.
So based on this, one doctor (and even the endoscopist) think it's still remission, second one disagrees. But they give the same therapy for different reason, lol. They obviously interpret the found ulcerations differently.
MY personal opinion is that I am in symptomatic remission, but that the 2 ulcerations can't be anything else but the beginning phase of Crohn's activity, which might or might not get worse.
Fecal calprotectin is also high, btw. (300+, but the lab couldn't give the exact number).

I am kinda thinking that a dose of corticosteroids would be best here, to kill the eventual inflammation until it worsens. And only then maybe Imuran.
Please note that I've got no symptoms at all, and my lab tests have been fine except for anemia (which has now gotten a bit better after iron infusions).

 

[Miss Underestimated]

That has to be very confusing! Did they tell you what the pathology report says? I would listen to the one who listens to the pathology report, personally.

 

[DustyKat]

Do you know if the duodenum was completely clear of inflammation?
Iron is primarily absorbed here, I see you are having IV infusions but you won’t maintain a suitable level if you aren’t absorbing a sufficient amount from your oral intake.

Are you female and menstruating?
If so you can’t rule this out as a compounding factor to your Crohn’s and surgery.

For the life of me I have absolutely no understanding of what the second GI is saying. :yfrown:
Imuran will treat active disease but it is very slow acting and not suitable as a starting point when flaring as it generally takes 3 months to become fully therapeutic and for some it can take as long as 6 months.
It is not uncommon to see evidence of disease at the proximal end of the anastomosis following resection and it can be as it appears to be with you, mild and physically asymptomatic but clinically you are showing evidence of disease. In these circumstances it would not be unusual to go directly to Imuran. I will reiterate here that Imuran is used as a maintenance medication. Perhaps another thing the GI may consider is Pentasa along with the Imuran. It will have a more immediate and direct effect on the disease that is there. I have never been a big fan of the 5ASA’s with Crohn’s but my son’s GI was able to pull up a couple of studies that showed it can be useful in post surgical ileal Crohn’s, this is one of the studies:

http://onlinelibrary.wiley.com/doi/10.1002/ibd.20909/full

…the numbers aren’t brilliant but any percentage added to what we are already doing to prevent a relapse is in my mind worth it. So I certainly agreed with the GI on that. Plus in the scheme of things Pentasa is pretty inoffensive if tolerated.

What supplements are you taking?

I supplement to deficiencies and when the kids have their routine bloods done, due to Imuran, every 2-3 months I also have the following done:

Iron Studies
Folate
B12
Vit D
Magnesium
Zinc

You will see from my signature in my previous what supplements are being taken.

These days a deep stable remission would mean you have no physical, clinical, endoscopic and histopathological abnormalities.

Dusty. xxx

 

[Miki]

To answer your questions: yes, duodenum was clear on the colonoscopy. Also celiac was ruled out on biopsy BUT my TTG was elevated. I have read that it's possible to have celiac despite negative pathology report and that it's good idea to take more samples from different locations. I don't think more than 1 or 2 were taken.
Regarding supplements, I take B12 (injections), vitamin D, folic acid.

In the meantime, after posting the topic and feeling relatively fine, I have developed a severe bleeding during my toilet visit and the sudden blood loss made me dizzy and weak. My hemoglobin dropped to 87 (was probably 110-120 before this episode). I went to ER and was hospitalized. During the night and day, it has remained at 87 so it was a one-time episode and no further bleeding, at least for now. My leukocytes are also slightly elevated, but my CRP is normal.

I suspect it could be the hemorrhoids (which were found on colonoscopy) but we'll see what the doctors say and do. I am feeling relatively fine again, as my body has adjusted.
I've had an unexplained anemia (but no visible bleeding till yesterday) for year and half now. I'll let my docs do the job, but what would be the best course of action now? Repeat the colono, which I did just a month ago?? Pill cam?
Could it be undiscovered angyodisplasia somewhere along my bowels?
I don't feel any typical symptoms of the disease, and don't think Crohn could have progressed significantly in just 1 month. My appetite is great, no pain anywhere.

 

[highlandsrock]

Azathioprine kept surgery at bay for 9 years after I came off of Prednisolone. Unfortunately I developed blood problems (low platelets), came off of it and ended up with surgery.

My GI would normally prescribe Azathioprine for maintaining Crohn's remission after surgery but not for me due to a low platelet count. Have just had final results from a bone marrow biopsy and it confirms Azathioprine as the likely culprit. (Platelets went down to 56 at their lowest, now up to 78)

So far I've stayed in clinical remission without any Crohn's meds so I'm keeping my fingers crossed. remission has been confirmed by two colonoscopies and a calprotectin test.

 

[kh216]

I agree with everything Dustykat regarding 6mp and Imuran. I am doing well on 6mp and Lialda now but it took a good 5 months before the 6mp started to work. I was on Entocort a good year while I was on 6mp and a couple of brief times, had to go on Prednisone. This was done while we had to figure out my correct 6mp dosage. 6mp and Imuran are very useful as steroid sparing drugs. That being said, I know that some people are better off using biologic meds or must get off of 6mp and Imuran because of side effects.

 

[kenvh]

I dont get it?? Why do people go into remission when only being on MP6 or AZA Imuran?
People do get remission with only being on those meds.
So I totally dont understand.
can someone explain?

 

[Miss Underestimated]

We're all different, and different things work for different people. I've been on Humira since 2012. In 2013 I still had some inflammation, and my Dr. put me on 6MP for a year - it kicked me into remission, and now since Nov. I take only the Humira. So far so good. So, I'd say make sure you have a Dr. you trust, and follow his/her advice.