About DANIL HAMMOUDI.MD Expertise answer all questions regarding this condition, treatment options and prevenbtion if any
Experience general surgery, expert to several web site and categories, answer about 300 crohn's disease question a month and practical experience for more than 4 years
Question My sister was just diagnosed with Crohns Disease. She had been in great pain - couldn't see the specialist for 3 weeks but ended up going to emergency because of the pain. They kept her in the hospital and tests showed she had Crohns. The dr. showed her the damage on x-rays or whatever it was - I don't have all the facts yet. She's in an extreme amount of pain, even with pain medication.
My question is this - what are the latest treatment options for this disease. She made need surgery to remove the damaged areas but is there any alternative? I've read that there are natural alternatives to heal these areas such as aloe vera juice, barley green, etc., etc. Is there any cure for this disease? A number of years ago she had ulcerative colitis and thought that was what this was. Do you think she had it back then and it was misdiagnosed or are they usually in conjunction with each other? My sister is very dear to me and I want to make certain she has all the most recent information to treat her disease. Thank you very much for volunteering your time.
Answer so far there is no cure for the disease but an antibiotics type treatment is tried out since the origin is a bug of the family of tuberculosis [she can look for clinical trials]
if the symptoms are great and she does not respond to treatment or she has complication surgery will be done, but this does not stop the evolution of the disease
FDA today licensed a new biotechnology product to treat patients with moderate to severe Crohn's disease, a chronic, incurable inflammatory bowel disease that causes diarrhea, cramping and abdominal pain and in some cases open holes (fistulae) leading from the intestine to the skin.
The new product, a monoclonal antibody called infliximab, is the first approved treatment for Crohn's disease. It is a genetically engineered antibody against a protein, tumor necrosis factor alpha, that promotes inflammation in the body. This antibody is manufactured using cells containing human and mouse antibody genes.
"Although not a cure, in the short-term, infliximab can have a dramatic impact on the quality of life of patients with severe forms of Crohn's disease," said Acting FDA Commissioner Michael A. Friedman, M.D. "We look forward to more long-term studies of the product so that patients and their doctors can use it in the most effective way possible."
Infliximab is indicated for the reduction of the symptoms of moderate to severe Crohn's disease in patients who have not responded well to traditional treatments, including corticosteroids and other immunosuppressants, and antibiotics. The improvement in patients who had taken infliximab was measured in terms of the number of liquid or soft stools, number and severity of abdominal cramps, and the overall sense of well-being. In a clinical trial, patients benefited most from the treatment within a two to four-week period following a single dose of infliximab. The percentage of patients who maintain benefits decreased over the next few months. Currently, data are limited and inconclusive on the product's long-term effectiveness.
In another clinical trial, the treatment reduced the number of draining fistulas that occur in some cases of Crohn's disease -- a benefit that lasted five months at most. There are no data on the retreatment of these fistulas.
The most common side effects were related to the intravenous infusion itself and included rash, low blood pressure, chills, and chest pain. These symptoms were generally temporary. Other common side effects included infections, some serious, that responded to antibiotic treatment. In addition, patients occasionally developed antibodies which could have been associated in rare cases with symptoms similar to ones seen in patients with systemic lupus erythematosus. These symptoms were also temporary.
Because short-term use of infliximab has benefited patients with a serious disease, the product has received accelerated approval. As part of that approval, the manufacturer has committed to studies in the near future to help answer questions about the long-term safety and efficacy of infliximab.
Infliximab is manufactured by Centocor, Inc. Of Malvern Pa., and will be marketed under the trade-name Remicade.
Crohn's disease is a long-lasting (chronic) inflammatory disease that primarily affects both the small and large intestines (bowel), but can also involve other parts of the digestive system. It causes severe redness and swelling of the intestines and ulcers (like a sore). Ulceration can cause a hole in the wall of the bowel. The scarring and the swelling may block the passage of food down the intestines, Most common symptoms of Crohn's disease include abdominal pain, diarrhoea, vomiting, fever, and weight loss. The symptoms may come and go.
How do you get Crohn's Disease?
Crohn's disease can appear anywhere in the small or large bowel. Its cause is unknown though it appears more frequently in developed countries and also in people who have a family member with Crohn's disease or ulcerative colitis. There is higher risk in people who smoke.
How serious is Crohn's Disease?
Sufferers can be affected in very different ways: some have mild symptoms even without any treatment while others experience very severe forms of the disease.
In mild forms, small erosions (wounds) called aphthous ulcers form in the inner surface of the bowel.
In more serious cases, deeper and larger ulcers can develop, causing scarring and stiffness and possibly narrowing of the bowel or obstruction. Deep ulcers can puncture holes in the bowel wall, which can lead to infection of the abdomen.
How long does Crohn's Disease last?
Crohn's disease lasts for many years throughout life. Many patients require surgery at some point and even then it can recur within 10 years. Half of these patients may then require further surgery.
How is Crohn's Disease treated?
The most commonly used medications in Crohn's disease are anti-inflammatory drugs, such as salicylate preparations (related to aspirin) and steroids (of the glucocorticosteroid type). For more serious cases, drugs that suppress the immune system (the body's defence system) are used or even surgery to remove part of the bowel.
Human growth hormone combined with a high-protein diet significantly eased the symptoms of Crohn's disease in three-quarters of patients with moderate to severe cases, a study has found.
Crohn's affects the digestive tract, causing persistent diarrhea, abdominal pain, bleeding and a breakdown of the intesetinal wall. About half of Crohn's patients require surgery to remove intestinal obstructions or repair holes in the bowel. No cure is known, although drugs can ease symptoms.
The study in Thursday's issue of the New England Journal of Medicine [AE Slomin, MD. A Preliminary Study of Growth Hormone Therapy for Crohn's Disease; NEJM 2000;342(22):1633-7] found that 11 of 19 adults treated with growth hormone while on a high-protein diet went into remission. Three others improved significantly. Eighteen patients taking a dummy drug while on a high-protein diet saw no significant improvement.
The study was supported by grants from Eli Lilly and Company and the Genetech Foundation for Growth and Development, a nonprofit organization that receives financing from Genetech Inc. Both pharmaceutical companies make growth hormone.
As many as one million Americans suffer from Crohn's disease, the Crohn's and Colitis Foundation of America said. Moderate to severe Crohn's disease is diagnosed in up to 120,000 people each year.
Several anti-inflammatory and immune-suppressing drugs can send the disease into remission but do not prevent long-term relapse. Other drugs prevent relapse in some patients but do not make the disease go into remission.
The leader of the new study, Dr. Alfred Slonim of North Shore University Hospital in Manhasset, N.Y., said growth hormone caused few harmful side effects in children and adolescents who had taken it for years.
If further studies find the growth hormone is effective for long-term treatment of Crohn's, it may prove safer than current remedies, Dr. Slonim said.
The cause of Crohn's is unknown, but one theory is that infections or hereditary factors weaken the intestinal wall, making it more susceptible to inflammation and tissue breakdown when it comes in contact with disease-causing organism. An exaggerated immune response may also play a role.
The first line of treatment for Crohn's disease usually includes prescription of sulfasalazine or medications containing mesalamine, an aminosalicylic acid that helps control inflammation. Sulfasalazine (Azulfidine®) contains a sulfa preparation and 5-aminosalicylic acid(5-ASA) and is generally prescribed for mild-to-moderate Crohn's disease which affects the colon. Patients who do not benefit from sulfasalazine or who cannot tolerate it may be put on mesalamine-containing drugs, generally known as 5-ASA agents, such as Asacol®, Dipentum®, Pentasa® or Rowasa®. These 5-ASA agents are useful in the treatment of mild-to-moderate Crohn's disease of the small intestine or colon. Rowasa®, which is administered by suppository or enema is reserved for treatment of disease in the rectum or lower colon. Possible side effects of mesalamine preparations include pancreatitis, pneumonitis, nausea, vomiting, heartburn, diarrhea, and headache, as well as those seen with sulfa or aspirin products.
Corticosteroids are frequently prescribed to control the destructive inflammation associated with Crohn's disease. Although these drugs often produce a dramatic and rapid improvement in active Crohn's disease, they can cause serious side effects. Some of the more common side effects associated with corticosteroid therapy include greater susceptibility to infection, increased appetite and weight gain, hypertension, hyperglycemia, cataract formation, osteoporosis, moon face and mood swings. Patients receiving corticosteroids require consistent, regular clinical and laboratory monitoring for the early identification of serious side effects. In addition, the efficacy of long term therapy with corticosteroids can not be substantiated.
Drugs that suppress the immune system are used to treat severe, active Crohn's disease that does not respond to standard therapy. Most commonly prescribed are 6-mercaptopurine or 6-MP (Purinethol®) and a related drug, azathioprine (Imuran®). Immunosuppressive agents work by blocking the immune reaction that contributes to inflammation. These drugs may cause serious side effects including pancreatitis, hepatitis, nausea, vomiting, and diarrhea and may lower a person's resistance to infection. Another disadvantage to this treatment is the slow onset of response which averages three to six months. Some studies suggest that immunosuppressive drugs may enhance the effectiveness of corticosteroids and when patients are treated with a combination of corticosterioids and immunosuppressive drugs, the dose of corticosterioids may eventually be lowered.
Methotrexate and cyclosporine may also be useful in the treatment of Crohn's disease that does not respond to standard therapies. Because of the potentially serious side effects associated with these drugs, including liver, lung and renal toxicity, the benefit of their use must be carefully weighed prior to the initiation of therapy. Clinical and laboratory monitoring for the early identification of side effects is an essential component of thetreatment plan for any patient receiving this therapy.
Antibiotics are used to treat bacterial overgrowth in the small intestine caused by stricture, fistula(e, or prior surgery. For this common problem, the doctor may prescribe one or more of the following antibiotics: ampicillins, sulfonamides, ciprofloxacin (e.g.,Cipro®), cephalosporin(e.g.,Keflex®), tetraccline(e.g.,Achromycin®), or metronidazole (e.g.,Flagyl®). Since corticosteroids may mask the signs of infection, antibiotics are often prescribed during the first ten days of steroid therapy.
Non-steroidal anti-inflammatory drugs or NSAIDS may be used to treat two frequent complications of Crohn's; arthritis and erythema nodosum. Because of NSAIDS limited efficacy, the efficacy of treatment must be weighed against the potential for complications, including the development of gastric and duodenal ulcers, bleeding and inflammation in the small intestine and recurrence of illness for those patients who had previously achieved remission.
Diarrhea and crampy abdominal pain are often relieved when the inflammation subsides, but supplemental medication may also be necessary. Several antidiarrheal agents could be used, including diphenoxylate(Lomotil®, loperamide (Immodium®), and codeine. Possible side effects of these agents include gas, bloating, cramping or constipation. Patients who are dehydrated because of diarrhea will be treated with fluids and electrolytes.
In August, 1998, the U.S. Food and Drug Administration approved the drug infliximab (brand name, Remicade™). Remicade™ the first in a new class of drugs is a monoclonal antibody directed against tumor necrosis factor-alpha (TNF-alpha) and is the first treatment approved specifically for Crohn's disease. TNF is a protein produced by the immune system that is believed to cause and perpetuate the inflammation associated with Crohn's disease. Infliximab binds to and neutralizes TNF-alpha in the bloodstream and in tissues, thereby preventing inflammation. Over 82% of patients in clinical trials achieved a clinical response and 48% had their Crohn's disease go into remission. When treating enterocutaneous fistulas, a complication of Crohn's in which there is evelopment of abnormal passages from the intestine to the skin resulting in leakage of the intestinal contents onto the skin, Remicade resulted in a >=50% reduction in the number of open fistulas in 68% of patients and complete closure of all fistulas in 55% of patients. Remicade is indicated for the treatment of moderately-to-severely active Crohn's disease, for the reduction of signs and symptoms in patients who have an inadequate response to conventional therapy. It is also indicated as a treatment for patients with fistulizing Crohn's disease, for the reduction in the number of draining enterocutanousfistulas.
Nutrition Supplementation
Nutritional supplements are frequently recommended; especially for children whose growth has been slowed, a common consequence of Crohn's in children. Special high-calorie liquid formulas are sometimes used for this purpose. A small number of patients may need periods of feeding by total parenteral nutrition (TPN). TPN can help patients who need extra nutrition temporarily, those whose intestines need to rest, or those whose intestines cannot absorb enough nutrition from food.
Surgery
Up to 75% of all people with Crohn's disease will require surgery to control symptoms or treat complications such as blockage, perforation, abscess, or bleeding in the intestine. Surgery to remove part of the intestine can reduce current symptoms of Crohõ's disease but cannot cure the disease. Surgical intervention may include colectomy, colostomy or resection. Since the inflammation tends to return next to the area of intestine that has been removed, surgical recurrence rates are substantial.
Recent studies reported that 41% of patients require additional surgical intervention after two years; 47% after three years; and as many as 59% after five years. In addition to the potential complications and substantial cost of surgical treatment, multiple resections could cause a condition known as short bowel syndrome and potentiate complications and costs related to that disorder. The efficacy of pharmaceutical management postoperatively is currently the subject of a number of clinical studies and medical debate. Some gastroenterologists favor the administration of mesalamine for all post surgical patients. Other physicians are awaiting the results of further studies to determine which patients will benefit from specific pharmaceutical management and how that treatment will impact quality of life.
Diet
No specific diet has been proved effective in preventing or treating this disease. Patients are encouraged to maintain a nutritious diet and to avoid any food that has exacerbated their symptoms in the past. With the availability of numerous treatment options; the need for patient-specific treatment, and the necessity of matching current patient need with the most effacious treatment, it is little wonder that case management of the patient with Crohn's disease can challenge even the most seasoned case manager. A subsequent article in the Disease Management Digest will address those challenges and will assist you to be even more successful in your efforts to provide quality case management services to the patient with Crohn's Disease.
