Strictures and Biologics

[copeland]

Hi,

I've had Crohn's for a while (12 years), but strictures are new to me. I just found out I have one last week in a colonoscopy.

I've read that Remicade (and maybe the other biologics) are not recommended with strictures because of the chance of scar tissue forming. Does anyone have a reliable source for that information? I think my doctor would like to put me back on Remicade, so I want to be prepared to discuss it intelligently.

There's a study cited on the forum wiki entry on strictures, but I can't access it.

Thanks!

-Dan

 

[my little penguin]

This prompted a new question about the use of anti-TNF agents (such as infliximab) in patients with strictures. A reader asks, "Considering their cicatrizing properties, could anti-TNF agents indeed worsen strictures?" Dr. Lashner's response to this question is below.

Infliximab for patients with Crohn's disease works best when taken by patients who have inflammatory-type disease. Patients who have stricturing-type disease often do not do as well on anti-TNF agents; therefore, these patients are usually excluded from clinical trials. Because infliximab works so well to reduce inflammation, the fibrosis left behind after resolution of the inflammation can cause symptomatic stenosis, stricture, or obstruction (SSOs). This issue was studied using the TREAT (Crohn's Therapy, Resource, Evaluation, and Assessment Tool) registry, a manufacturer-maintained registry of 6290 patients with Crohn's disease in which about half of the patients were treated with infliximab and the rest were treated with alternative non-biologic anti-inflammatory agents.[1] The rate of SSOs in infliximab-treated patients was about twice as high as in controls (1.95 events/100 patient-years vs 0.99 events/100 patient-years). The adjusted odds ratio was 1.7 (meaning that infliximab-treated patients had a 70% higher rate of SSOs), but this effect was not statistically significant. Still, it is likely that infliximab, and other anti-TNF agents, induce stenosis and should be used with caution in patients with stricturing-type Crohn's disease. Also, patients with inflammatory-type Crohn's disease who have been successfully treated with infliximab should be carefully observed for the development of obstructive symptoms

From
http://www.medscape.com/viewarticle/729747

 

[copeland]

Thanks!

Just realized after clicking on your link that accounts there are free, so I'll sign up and read the whole thing.

 

[24601]

Hi, good luck with your decision copeland! I hope you don't mind if I tell my story below just for the benefit of anyone who may be in a similar situation and worried about this issue - it's completely different to your situation though so I realise not directly relevant

I worried a lot about this when I was first offered infliximab in 2000/2001 as I already had strictures and severe obstructive symptoms. My doctor told me that I had to be prepared that it might precipitate emergency surgery and I declined to have it since surgery was inevitable and already planned. I have fairly extensive disease throughout the jejunum and ileum and in that first surgery my surgeon removed 37cm of ileum and performed 11 strictureplasties throughout the jejunum and ileum and left active disease since there was no option of cutting it out and leaving me with enough small bowel.

This concern about worsening strictures seemed to put off some of my doctors in the future too and I didn't try infliximab until 2010 after 2 further surgeries for strictures (6 strictures in 2005 and several more in 2009).

Infliximab and humira (combined with methotrexate) are the only meds that have helped reduce inflammation for me and since it would seem my bowel forms strictures very easily, it's important to control the inflammation to reduce the need for surgery and loss of small bowel. On balance for me, despite having stricturing Crohn's, it is an appropriate and helpful treatment.

I just wanted to illustrate that even though it's a concern and as quoted above "should be used with caution in patients with stricturing-type Crohn's disease" it certainly still has its place in treating some patients with strictures

 

[shamrock15]

I would have to second 24601. I too have stricturing crohn's and wish I was put on remicade much earlier. Between 2000-2006 I had 5 surgeries as a result of strictures. This has included 4 resections, putting in an ostomy and removing it later. I have lost count of the number of strictureplasties I have had done, but I recall it being in excess of 15. I was put on remicade in 2008 I believe, and I haven't had any new strictures pop up since then. I have been dealing with a rectal stricture since before then, and it has required one or two dilatations in that time. A far cry from what was an increasing tempo in surgeries.

I haven't missed a single day of work in that time as a result of crohn's attacks (kidney stones though are a different matter unrelated to remicade as far as I know). Remicade is the ONLY medication that has truly worked for me with my crohn's.

 

[edentenley]

I have stricturing Crohn's and am on Humira and it is the only thing that has helped me feel normal. I had surgery in February to remove a large strictured area, and continue to take Humira every two weeks. I had no hesitation trying it and no hesitation telling everyone how much it helped me.

Everyone is different though, so definitely talk with your doctor. Good luck!