As many of you will know my favourite treatment of Crohn’s disease is DIET. I very rarely use Infliximab, in fact only 2 patients in the last 5 years have needed a course. This was initially because of anxiety over its propensity to cause infection and also because of the cost. Further experience has shown (to quote Gastroenterology 2013 144 846) although (Infliximab) is a significant advance, the majority of patients treated with an anti-TNF agent develop either primary or secondary non-response and then subsequently fail treatment with an alternative agent in the class.
The development of new monoclonal antibodies is therefore crucially important. A recent trial studied the effect of ustekinumab in moderate to severe Crohn’s disease (N Eng J Med 2012 367 1519-28). Ustekinumab inhibits interleukin 12 and 23 which are believed to be important in the development of Crohn’s disease. The trial was on 526 adults in 153 centres in 12 countries who had failed to respond to a TNF antagonist. They received varying doses of ustekinumab or placebo, both to induce remission and as maintenance treatment. At week 6 a significantly greater response was achieved by 39.7% of the highest (6mg/kg) ustekinumab group compared to 23.5% of placebo. Smaller doses did not produce a significant improvement over placebo. The proportions achieving clinical remission after 22 weeks were also higher with ustekinumab than with placebo. There were no serious side effects.
This may be therefore a further useful addition to the biological treatment available for Crohn’s disease, although further trials are awaited.
Comparison with the success rates achieved by patients who take Enteral feeds for a full 2 weeks (80-100% remission) however, shows yet again how important it is for patients with Crohn’s to try dietary therapy if possible.
On the subject of drug therapies, I have recently received the following question:
“I understand that over the last 10 years, evidence has been discovered of “low grade inflammation” in some subgroups of patients with IBS. And that, on this basis and for additional reasons, some researchers believe there may be something of a continuum between IBS and IBD, rather than a sharp dividing line. Yet gastroenterologists seem on the whole unwilling to prescribe ‘IBD medications’ without definitive evidence of IBD (visible in scope, or calprotectin score, etc). Is there no justification for an ‘empirical’ approach, in appropriate cases? From a patient perspective it seems overly restrictive.”
- It is true that some cases of IBS show mild inflammation and that there may possibly be a continuum from IBS to Crohn’s disease. However, this does not mean that drugs for IBD should be freely used for IBS. Firstly, many of these drugs have serious side-effects whereas IBS is virtually always benign, so that the risk of drug side-effects is not justified. Secondly, IBS can almost always be straight-forwardly and successfully managed (see Prof Hunter’s book, Irritable Bowel Solutions, published by Vermilion, London in 2007.) so that expensive and potentially dangerous drugs are not needed.”
This article was first published on the original crohns.org.uk blog. Research has moved on since, so please check current advice with your IBD team.