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ECUPA2010

Crohn's Treatment

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Does anyone know if for inflammation of the ileum from Crohn's Disease what drugs would be most effective and not costly? I've heard different drugs target different parts of the GI tract. What about Asacol? I have heard that Asacol might not work on inflammation in the ileum. Is there any truth to that?

 

I have heard of a combo of 6-MP and Remicade. I don't know about 6-MP, but I have heard that Remicade can be quite expensive (as well as Humira).

 

Then, there's that whole risk of lymphoma.

 

Any help on this?

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Do you have access to uptodate.com? Lots of good material can be found there on Crohn's. Concerning Asacol (mesalamine) use in the ileum: "Mesalamine (Pentasa, Asacol) at a dose of 3 g/day should be considered as long-term therapy with the hope of preventing disease relapse".

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asacol is not very effective for Crohn's, more so for ulcerative colitis.

 

otherwise, there are various forms of immunomodulators (6mp is one) and TNF-a inhibitors (remicade/infliximab is one). It seems the only disease modifying agents are the TNF inhibitors and early and aggresive treatment with them is the only thing that has shown to have meaningful impact on the course of the disease. Corticosteroids are associated with increased morbidity and mortality in crohns. You are also right that combination 6MP and Infliximab appears to be correlated with lymphoma. I dont believe there has been a case of remicade induced lymphoma without concomittant immunomodulator usage. You are alos correct that remicade is expensive at ~1k per dose.

 

Are you a PA student or PA? Or are you asking this for personal information? If you are in primary care, you really should consider letting GI manage these folks.

 

Sincerely,

Chris

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Does anyone know if for inflammation of the ileum from Crohn's Disease what drugs would be most effective and not costly? I've heard different drugs target different parts of the GI tract. What about Asacol? I have heard that Asacol might not work on inflammation in the ileum. Is there any truth to that?

 

I have heard of a combo of 6-MP and Remicade. I don't know about 6-MP, but I have heard that Remicade can be quite expensive (as well as Humira).

 

Then, there's that whole risk of lymphoma.

 

Any help on this?

All of the medications for Crohn's are going to be expensive. The cheapest is probably generic Mesalamine. Asacol is generally not effective for Crohn's since it only delivers the medication to the colon. We usually use Pentasa since it delivers drug to the whole bowel. Another possibility is Entocort which is a topical corticosteroid that is primarily delivered to the ileum.

 

6-MP (or Imuran for those west of the Mississippi) and Remicade are very effective treatments. While they do have a lymphoma risk, the risk of dying from untreated disease or cancers associated with untreated disease is higher.

 

There are various programs to help people without insurance for all of these drugs.

 

David Carpenter, PA-C

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Thanks. This is actually for myself. I just so happen to be a PA student. My GI doc is actually referring me to an Allergist as well, b/c my eosinophils were elevated at the time he had to put me on prednisone. He said there may be a food allergy issue as well (oh joy!). I voiced my opinion to him about my lymphoma fear, and he understood but told me I would have another flare-up. I am being slowly taken off the prednisone and in a month I see him again. To be honest, I am scared about the lymphoma issue and I'm completely lost in what I should do. I guess I may just do the Remicade/6-MP like he said, but cost, time (as if PA school isn't taking up enough time now I've got to go in every 8 weeks and get IV injections?! And it takes 2 hours?), and cancer risk are not very inviting. I have mild inflammation and ulceration, but nothing has even been mentioned of fistulas...just a possible obstruction in my ileum if the inflammation gets bad enough...and it hurts VERY bad when I have an attack.

 

I know there are rules/laws/etc. that make many of you hesitant in telling me what to do, but if you were me (knowing what you know about side effects, being in PA school, cost--I have BCBS and I think it will cover a good portion of the medicine, but I'm already a poor PA student :) ), what would you do?

 

Thanks for your help

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I would speak about this with my provider to determine the best course. The only person that can manage your care and give you medical advice is the person treating you.

 

If you want a second opinion you need to find another GI doctor in your area.

 

I think you are justified in asking why BOTH 6MP and remicade? Why not just remicade? Ask if he is just planning on having you on 6MP for the first 6 months to decrease antibody formation or if he is looking to keep you on it long term.

 

Best of luck.. You can get through PA school with Crohn's disease. No problem. I promise. Don't let your diagnosis affect your dreams.

 

Chris

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My doc mentioned that actually, but just said that it was there and that if I decided to do something like that, he wouldn't try and stop me. I can't help but not want to do that. Maybe it's all that negative publicity parasites get.

 

If I have attacks on average every year or so (which isn't too bad from what I hear), compare that to all the side effects (what is the risk of lymphoma? I've heard something like less than 1%), would it be worth it to go on meds?

 

There doesn't seem to be a real definite "no more flare-up" drug anyway, right? Remicade and all those drugs don't prevent relapses...they just prolong remission, right? My doc told me to think about what I want to do. Unfortunately, I don't know a whole lot about it. I've researched and researched, but I'm simply torn between what to do. All I know as a patient, is that I do NOT want cancer!

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Guest obyomeni

Hi ECUPA2010,

Have you heard of Cimzia? It's a new drug though---came out April 22, 2008. It has the same side effects as the other ones. The test group is very small, but, so far, it's FDA approved.

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I have heard of it, but that goes back to the whole lymphoma issue. If I live to be 80 years old, that puts me on these drugs for over 50 years! Combine that with a 1/1000 chance of lymphoma, and it's not to appealing.

 

I guess it all comes down to this: I have had attacks (diarrhea, vomiting, 10 on a scale of 10 abdominal pain) only about every year or so. Between attacks, I'm just fine. That's why I think it took 10 years to get the diagnosis--I only had attacks every so often.

 

The prednisone is working, but I'm not sure how effective these other drugs will work, and they don't cure the disease, so I'm still at risk of having attacks. If I have them every year or more, what good will the drugs do? I'm not constantly having diarrhea, abdominal pain, etc.

 

I have been contemplating the Specific Carb Diet too, but would it just be overkill to limit myself to a restrictive diet and take BIG drugs?

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I am hearing remicade without Imuran for certain age groups secondary to lymphoma risk. The Imuran is cheap, at least compared to the 7-10 thousand cost per remicaid infusion. With a fistula remicade seems like the only option. Would be interested in any ongoing studies you know of using either remicade, imuran or both. thanks

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Remicade is the only non-surgical treatment I am aware of for fistulizing crohn's. The company (JNJ) has a great deal of information on medversations.com and Remicade Re lymphoma, patients with autoimmune disease are already at a higher risk than the general population. As to the question does infliximab increase the risk, the data are being studied. No clear conclusion can be drawn at this time. Bottom line: if the benefits outweigh the risks the therapy should be an opion for the patient.

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