Top Down or Bottom Up Approach

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Apr 11, 2012
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Curious for your thoughts... I had difficulty searching for a similar topic - I'm sure there's a discussion somewhere but I don't know enough, yet, to know what to be searching for.

I was just diagnosed with Crohn's - 4 days ago. I'm not in the process of sorting out treatment options and healing from my hospital stay. My GI doctor wants to do a top down treatment approach - hit this hard with either azathioprene or 6-MP in combination with an antiTNF (e.g. Remicade). I'm not against this approach - I'm just doing my due diligence.

The top down approach appears to be hinged off of the Sonic Trial which, for the most part, shows fantastic results (I like those low P-values). It would be great if there were more than one study (I can't seem to find one but this is a relatively new piece of research).

I'm curious if anyone did a bottom up approach (start with azathioprene/6-MP and add the antiTNF? I'd love to hear your thoughts while I try and collect mine.
 
Howdy there. We've had small discussions on approach methodology here and there, but not a whole lot, maybe this thread can become the go to thread in the future! If you're willing to share what you find as you perform your due diligence, it would be greatly appreciated and others would no doubt benefit. Have you seen this?

My personal opinion is the approach should be patient specific. There are so many variables when it comes to Crohn's Disease that breaking it down into two approaches is overly simplistic in my opinion. For example, if a patient has new onset disease and is presenting as intestinal inflammation, then I can see how a top down approach may be beneficial. I certainly understand the rationale behind the top down approach and the data is good. But what if they have severe fibrotic stricturing that is also inflamed? Considering that it has been shown that antiTNF's like Remicade can lead to additional scarring which they promote during healing, such an approach might be detrimental. Or what if the patient would be willing to stick to an elemental or enteral diet? Considering they have the same remission rates as prednisone without any of the side effects, shouldn't patients be educated about this possibility? Every top-down approach article and study I've ever read never compared new-onset disease treatment with elemental/enteral nutrition data. Or what about utilizing corticosteroids or elemental diet to reduce inflammation without scarring then go on the biologic to maintain or induce remission without the resulting scarring since the inflammation is already significantly reduced or gone.

And of course then there are the considerations of potential side effects and cost.

It's a tough one and I really respect you for doing your research :)
 
If you're willing to share what you find as you perform your due diligence, it would be greatly appreciated and others would no doubt benefit. Have you seen this?

I have not seen that thread and will certainly chew on it in the morning. Thanks! I can compile what I find but I certainly appreciate the patient specific sort of care. At the moment, the Sonic Trial appears to be the only literature I've found on combination treatment but I admit my searches thus far have only been cursory. It would be awesome to find some sort of meta analysis (to me, that's a sign that the research area has some maturity).

At every step of this, I've asked my doctors of literature references and they've generally been accommodating. Some medical jargon is beyond me (Dammit Jim, I'm a mechanical engineer - not a doctor!) but the statistics side of things I'm extremely familiar with.

If things were as easy as comparing efficacy, this would be incredibly easy :p

Thanks again, you've given more more leads to springboard from :thumleft:
 
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