Dr. Brian Bressler, MD, MS, FRCPC (biography and disclosures)
What I did before
The treatment of Crohn’s disease has, for the most part up until recently, been centred on controlling clinical symptoms associated with this disease. The reason behind this approach is largely due to the fact that we did not have therapy that could change in a reliable way the inflammatory response leading to the abnormal function of the GI tract causing the symptoms of Crohn’s disease. A mainstay of treatment was Prednisone, as this does consistently improve clinical symptoms associated with Crohn’s disease. Unfortunately, it has been known that it has no impact on changing the natural history of Crohn’s disease, specifically a reduction in surgeries or hospitalizations. We have always known the side effects and toxicities associated with steroid use. What has become more concerning in recent prospective cohort studies has been an increase in mortality and infections in patients with Crohn’s disease exposed to Prednisone.
What changed my practice
As we have learned more behind the abnormal immunological response triggering inflammation associated with Crohn’s disease, medications have been developed to specifically address this problem. The most effective medications for treating Crohn’s disease are anti-TNF inhibitors. Infliximab and Adalimumab are the two medications in this class available in Canada. They have been shown, like Prednisone, to quickly induce clinical remission. Unlike Prednisone, they have also been shown to keep patients in a long-term clinical remission. The most unique result in the clinical trials evaluating these medications has been the ability of both agents to heal the bowel. We have known for a long time that, although Prednisone makes patients feel better, it has no impact on what the bowel looks like. It has always been assumed, but now it has been proven, that healing the bowel changes the natural history of this disease by reducing the need for surgeries, fistula formation and hospitalization. These medications have also shown the ability to reduce the requirement of Prednisone in patients with Crohn’s disease.
What I do now
A goal in treating patients with Crohn’s disease is to return their quality of life back to its normal state, with the avoidance of Prednisone. I counsel each patient when I first diagnose them with Crohn’s disease that in this era we are now more than ever able to effectively treat their Crohn’s disease to the point where it should have very little, if any, impact in their life. Effectively treating the inflammation in patients with Crohn’s disease has now allowed us to treat not just the symptoms associated with Crohn’s disease, but the disease itself. My take home message to anyone involved in the care of patients with Crohn’s disease is to refer patients with Crohn’s disease to a gastroenterologist to review their treatment plan if the patient’s quality of life is impaired by their symptoms attributed to this disease. Furthermore, when patients are doing well encouraging compliance for adhering to their treatment plan is important to maintain their quality of life.
Rutgeerts et al. Comparison of scheduled and episodic treatment strategies of infliximab in Crohn’s disease.Gastroenterology 2004;126:402-413
Rutgeerts P et al. Adalimumab Induces and Maintains Mucosal Healing in Patients with Moderate to Severe Ileocolonic Crohn’s Disease — First Results of the EXTEND Trial. Gastroenterology 2009;136(5 Suppl 1):A-116.